Application for Employment

Please complete in black ink or type. CVs will not be accepted.

Please return to Human Resources,

Aquarius, 2nd Floor, 16 Kent Street, Birmingham B5 6RD

Alternatively to meet the closing date fax to 0121 622 8189 although this must always
be followed up by a signed hard copy as soon as possible.

Please read the guidance notes before completing this form.

Position Applied For: General Assistant

Location: Head Office, Birmingham

Job Reference: HO/09/7

Section 1A
Personal Information
This section of the form will be detached from your application and held by Human
Resources.

Surname Date of Birth

Forename(s) Email

Telephone Numbers Address

Mobile:

Home:

Business:
General
Are there any adjustments that may be required to be made should you be invited for
interview?

Are there any restrictions to your residence in the UK which might affect your right to take up
employment in the UK? Yes No

If yes, please provide details:

If you are successful in your application, would you require a work permit prior to taking up
employment? Yes No

Referees
Please give the names and contact details of three referees who have agreed to be consulted
concerning your likely suitability for the post, two of whom should preferably be from your
current/most recent employer. References will be taken up after shortlisting, please clearly
indicate any that you do not wish to be taken up at that stage by ticking the appropriate box.

1. Current/most recent employer

Name

Address

Telephone

Email

Occupation

Permission given to contact this referee prior to interview Yes No

2. 3.
Name Name

Address Address

Telephone Telephone

Email Email

Occupation Occupation

Permission given to contact this referee prior Permission given to contact this referee prior
to interview Yes No to interview Yes No

2
 HO/09/7
Section 1B
Personal Information
This section of the form will be detached from your application and held by Human
Resources. This information will be kept strictly confidential and only disclosed to the
Senior Manager.

General

When could you start work?

Health

How many days have you been absent from work due to illness during the past 12 months?

If more than 10 days, please give details:

Please tell us about any health or personal information which is relevant to this application:

Rehabilitation of Offenders Act 1974

Exceptions Order (1975)

Because of the nature of the work for which you have applied, we need to ask you to disclose
any convictions. You are not entitled to withhold information about convictions which
otherwise might be considered “spent”. In the event of employment, any failure to disclose
such convictions could result in dismissal or disciplinary action by Aquarius. Any information
given will be completely confidential and will be considered only in relation to an application
for positions to which the Exceptions Order applies.

Do you have anything to disclose? Yes No

If yes, please give details (date, type of offence/sentence/fine imposed)

Signature …………………………………………………… Date …….……………….

3
 HO/09/7
Section 2

Present/Most Recent Employment and Competencies

Your application will be assessed for selection based on the information given in this
section of the form.

In the Statement in Support of Application you are asked to outline how your
knowledge, skills and experience meet the competencies required for this role, as
outlined in the Person Specification. You should draw on your experiences from your
current or previous roles or other relevant situations, such as activities outside work.
You may find it useful to break this section down into the subheadings as outlined in
the Person Specification.

Present/Most Recent Employment

Dates Employer/Position/Salary

Details of duties/responsibilities

4
Statement in Support of Application
(Continue on a separate sheet if necessary)

5
 HO/09/7
Section 3

Education, Qualifications and Employment History

The information in this section of the form will be considered by the selection panel
only after shortlisting has been undertaken based on the information in section 2.

Education and Professional Qualifications (from Secondary)

Dates Establishment Courses and Qualifications

Previous Employment

Dates Employer Position, salary, brief details of Reason for

responsibilities leaving

6
Data Protection Statement
The information that you provide on this form and that obtained from other relevant sources will be used to process your application for
employment. The personal information that you give us will also be used in a confidential manner to help us monitor our recruitment
process.

If you succeed in your application and take up employment with us, the information will be used in the administration of your employment
with us and to provide you with information about us or third party via your payslip. We may also use the information if there is a complaint
or legal challenge relevant to this recruitment process.

We may check the information collected with third parties or with other information held by us. We may also use or pass to certain third
parties information to prevent or detect crime, to protect public funds, or in other ways as permitted by law.

By signing the application form we will be assuming that you agree to the processing of sensitive personal data (as described above) in
accordance with our registration with the Data Protection Commissioner.

Declaration
I declare that the information I have given in this application is accurate and true. I
understand that providing misleading or false information will disqualify me from the
appointment OR, if appointed, may result in my dismissal.

Signature …………………………………………………… Date …….……………….

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Section 4 HO/09/7

Equal Opportunities Monitoring

This section of the form will be detached from your application and held by Human
Resources for information and monitoring purposes only. This section will not be
seen by the panel.

Aquarius recognises and actively promotes the benefits of a diverse workforce and is
committed to treating all employees’ with dignity and respect regardless of race,
gender, disability, age, sexual orientation, religion or belief. We therefore welcome
applications from all sections of the community.

White:
British Irish Any other white background*

Mixed:
White and Black Caribbean White and Black African White and Asian Any other mixed background*

Black or Black British:

Caribbean African Any other Black background*

Asian or Asian British:

Indian Pakistani Bangladeshi Any other Asian background*

Chinese or Other Ethnic Group:

Chinese Other Ethnic Group*

*Please specify

Gender:
Male Female

Do you consider yourself to have a disability: Yes No

If yes please state nature of disability:

The Disability Discrimination Act defines disability as ‘A physical or mental impairment which
has a substantial and long-term effect on the person’s ability to carry out normal day-to-day
activities’.

How did you become aware of this vacancy? Please give details of the publication or
website: