Jobmatch Application Form

Jobmatch Application Form

Please answer all questions as incomplete applications may delay acceptance on the scheme.

1.PERSONAL DETAILS

Title Mr / Mrs / Miss / Ms

Name (in full)______

Address______

______

______

Telephone No.______Mobile No: ______

Email Address______

Date of Birth______National Insurance No ______

2.EDUCATION/TRAINING (Use a separate sheet of paper if necessary)

Dates attended / School/College/Training Provider / Course Details/Qualifications

3.WORK EXPERIENCE or VOLUNTARY WORK (List any unpaid placements)

Dates attended / Employer’s name and address / Details of Duties

4.PAID EMPLOYMENT(use a separate sheet of paper if necessary)

Dates attended / Employer’s name and address / Details of duties and reason
for leaving

5.DISABILITY / HEALTH

What disability/disabilities do you have?

______

______

Do you have any health difficulties? If ‘yes’ please give details ______

______

Are there any other issues that may affect the type of work you can do? Yes / No

If ‘yes’ please give details ______

______

6.BENEFITS RECEIVED (tick all that apply)

Jobseeker’s Allowance / Disability Living Allowance
Employment Support Allowance / Council Tax Benefit
Incapacity Benefit / Child Tax Benefit
Income Support / Working Tax Credit
Housing Benefit / Other

7.OTHER INFORMATION REQUIRED

How did you hear about JOBMATCH?______

Are you using any other Bromley Mencap services? ______

If ‘yes’ please give details ______

Do you have a Care Manager? Yes No

If yes, please provide their name and address ______

______

______Tel: ______

If you do not have a Care Manager are you registered with any of the following services:

The Work Programme Yes Date started: ______No

The Work Choice Programme Yes Date started: ______No

Other employment programme? Yes Date started: ______No

If yes, please provide details ______

PLEASE COMPLETE THIS QUESTION
Once we receive your form we will invite you to our offices to discuss your application.
Please let us know what days and times are best for you to attend.
______

8.DECLARATION

I confirm that the information provided on this form is true and to the best of my knowledge

Signed:______Date: ______

If this form has been completed on behalf of the applicant please sign and complete the following:

Name: ______Relationship to the applicant: ______

Address: ______

______Telephone No: ______

Signed: ______Date: ______

Applicant’s Ethnic background – please tick

White / Pakistani
Black – Caribbean / Bangladeshi
Black – African / Chinese
Black – Other / Other
Indian / Not sure

Jobmatch Applic Form March 2014