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Please feel free to use additional pages if this form is not big enough

LEICESTER SAMARITANS

APPLICATION: Assistant to Branch Secretary

Surname (Family Name) / Title
Forenames
Date of Birth / Nationality
Do you require a work permit? / National Insurance No
Home Address
Postcode
Home Tel. No / Daytime Tel. No
Mobile Tel. No / E-Mail
Present or Most Recent Employer + address
Post Title
Brief description of your duties
Current or Last Salary / Notice Required
Date Started (month, year) / Date Left
References. We plan to ask for two references before interviews. If you would like us to tell you before we do this then please tick the box.
Name / (1) / (2)
Address
Tel. No
E-Mail
Tick if we should not contact just yet
Career History
Employer + Address / Date Started (Month, Year) / Date Left (Month, Year) / Post + Brief description of Duties
Education Details
Place of Education / Start + Finish Dates (Month, Year) / Qualifications Obtained
Other Information in Support of Your Application (Please use a separate sheet to tell us your reasons for applying, previous experience you have, training courses you have attended and your skills and abilities which would help you to fill this post)
I confirm that the information given in this application is correct to the best of my knowledge and that I am in possession of the qualifications I claim to hold. I understand that any misrepresentation may render me liable to dismissal should I be employed. I give my consent for Leicester Samaritans to record, process and validate my personal information in line with the Data Protection Act 1998 and all other legislative provisions. My consent is conditional upon Leicester Samaritans complying with its legal duties and obligations relating to the recording and use of this information
Signature / Date