KINGSTON UPON THAMES ASSOCIATION for the BLIND

An Equal Opportunities Employer

Application Form

Part Time Development Worker

The position requires an Enhanced Disclosure & Barring Service Certificate (DBS, previously CRB) and has a six month probationary period.

Please return to: 2A Sussex Road, New Malden, Surrey KT3 3PY with a covering letter outlining your interest and suitability for the position.

Confidential

Surname: First Name: Title:

Address:

Post Code:

Home telephone number:

Mobile/Daytime contact phone number:

Email address:

National Insurance number:

Do you hold a current driving licence? Yes / No

Do you have a car you can use? Yes / No

Do you need a work permit? Yes / No

Disability

We want to increase the opportunities for disabled people to work with us. If you have a disability, please tell us in the space below if there are reasonable adjustments we can make to help you fulfill the position:

Health

Please give details in the space below of any medical problems that may cause you to take time of work. If we offer you the job we may require you to have a medical:

Education and qualifications

School, College,
University, Other / Dates Attended:
From/To / Qualifications: Subject and Grade

Employment

Please give details of your previous employment starting with your present or last employer. Continue on another sheet if necessary.

Employer’s Name and Address / Dates From/To / Position / Salary On Leaving / Reason for Leaving

References

Please give details of two referees below. One of these should be your present or last employer and the other should be another employer if possible:

1. Name:

Company:

Position:

Address:

Post Code:

Telephone number:

Email:

2. Name:

Company:

Position:

Address:

Post Code:

Telephone number:

Email:

I confirm the information on this form is correct. I understand that if I tell you something which I know is wrong or misleading, or I do not give you information which is relevant to my application, you may reject my application or, if I get the job, take disciplinary action, including dismissal.

Signature: Date:

4 31/05/2017