APPLICATION FOR EMPLOYMENT

1. POST TITLE: Referral Coordinator/ Senior Support Worker

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2. CLOSING DATE: 26 July 2013

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3. REFERENCE:0019

4. PERSONAL DETAILS
Surname (Mr/Mrs/Miss/Ms/Other)
First Name / Address (including postcode)
Home Tel No:
Mobile Tel No:
Email:
Do you have a disability?
If registered disabled, please state the nature of your disability. / Do you hold a current driving licence? Yes/No
Do you own a car? Yes/No
How did you learn of this vacancy
Please give brief details of any serious injury/illness in the last 5 years
Please indicate how many days sick taken during the last 2 years, on how many occasions and a brief indication for the reasons / Are you related to or do you have any connection with an employee or management committee member of Outward? If yes, please give details.

5. PRESENT EMPLOYMENT

Job Title /

Employer’s Name and Address

Salary / Scale
Other benefits
Start date / Notice Required
Please outline your duties, identifying your role in the organisation and if applicable, give details of staff who report to you.

6. EMPLOYMENT HISTORY

Please give full details of your employment history and account for any gaps.
Employer’s Name and Address / Post held /
Dates
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Reason for leaving

7. VOLUNTARY WORK EXPERIENCE

8. EDUCATIONAL & PROFESSIONAL QUALIFICATIONS

Institution

(school, college, professional body etc) /
Qualifications
/
Dates

9. RELEVANT TRAINING COURSES ATTENDED (Please list only those relevant to the post applied for)

10. PERSONAL STATEMENT

  • Please tell us your reasons for applying and how you meet the criteria identified in the job description and person specification
  • You will be shortlisted on the evidence you provide on this form so please provide background and context
  • For example, if the person specification requires ‘Experience of providing support to a vulnerable service user group’, tell us what you have done in the past to demonstrate you meet this criteria
  • You must give examples to illustrate your experience
  • If you need additional space, please continue on a separate sheet.

11. REFERENCES

Please provide details of two persons other than relatives who have agreed to give an opinion of your ability, experience and qualifications. One must be your current or most recent employer. These references must cover the period of the last three years at least. If you have had more than two employers in this time, please list them all as referees. Please do not give more than one reference from the same employer or organisation. Please do not give relatives or work colleagues who are at the same level as you or below as referees.
Name / Name
Position
Organisation
Address
Tel No.
Email. / Position
Organisation
Address
Tel No.
Email.
Capacity in which you are known to the referee / Capacity in which you are known to the referee
May we contact this referee if you are shortlisted?
Yes/No / May we contact this referee if you are shortlisted?

Yes/No

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