Application Form

Activities and Interests
Describe your interests*
If offered this position, do you intend to continue working in another capacity?*

YesNo
Please give details*

Monitoring Form
This form asks you to provide information from which your perceived religious affiliation can be determined. The following explains why we are fairemployers. We do not discriminate on the grounds of religious belief, political opinion, gender, race, disability, or age. We practise equality of opportunity in employment. Most important of all we operate the merit principle; ie. we select the best person for the job or promotion or opportunityin employment. To do this we need to monitor the perceived religious affiliation of our employees and job applicants. Unless we get this informationwe cannot show openly that we are fair employers. Therefore we are asking you to help us by indicating the community to which you belong. Theinformation that you are asked to supply will be treated in the strictest confidence and protected from misuse. It will be used only for the purpose ofmonitoring our equality of opportunity in employment policies. The terms of the above information are as recommended by the Government.
Are you*

MaleFemale
I am*

A member of the Roman Catholic CommunityA member of the Protestant CommunityA member of neither the Roman Catholic or the Protestant Community

Medical Questionnaire
ALL INFORMATION WILL BE TREATED IN THE STRICTEST CONFIDENCE

WARNING: This form contains a number of questions about your past and present health and physical condition. Should you give particulars or answers which are found to be false you may be liable to disqualification or if appointed to dismissal. The willful suppression of any medical fact will be similarly penalised.
Family Doctor*

First NameLast Name
Telephone Number*

Country CodePhone Number
Address*

Address Line 1

Address Line 2

Town/CityCounty

Postcode

	Yes	No
Do you require any special working arrangements for this role?

Question 2

Please select as appropriate, and give details e.g. length of illness, approx. dates, treatments, etc., in the space provided at the bottom of each section.

	Yes	No
Are you at present under any medical treatment or observation or have you been during the last five years?
Have you ever undergone an operation or had radio therapy treatment?
Have you ever been medically rejected for service with any public body, insurance company or government body?
Have you any deformity, physical or speech defect?

Question 3

Please select as appropriate, and give details e.g. length of illness, approx. dates, treatments, etc., in the space provided at the bottom of each section.

	Yes	No
Is your eyesight satisfactory for all normal purposes with or without glasses?
Do you wear contact lenses?
Have you ever suffered from any injury or disease of one or both eyes?
Are you colour blind?

Question 4

Please select as appropriate, and give details e.g. length of illness, approx. dates, treatments, etc., in the space provided at the bottom of each section.

	Yes	No
Is your hearing good in both ears?
Have you ever suffered from any ear disease?

Question 5

Please select as appropriate, and give details e.g. length of illness, approx. dates, treatments, etc., in the space provided at the bottom of each section.
Yes No

Are you able to work at heights?
Please provide details.*

	Yes	No
Are you able to work at heights?

Question 6

Please select as appropriate, and give details e.g. length of illness, approx. dates, treatments, etc., in the space provided at the bottom of each section.
How many days have you lost due to illness during each of the last two years? Please give details.*

Declaration
I declare that all the foregoing statements are true and complete to the best of my knowledge and belief, and any false information could lead to my dismissal. I understand that I may be required to undergo a medical examination. I consent to my doctor being approached for further information, including medical reports if the company considers it necessary.
Signature*

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To be countersigned by Parent/Guardian if under 18

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Date*

DayMonthYear
Date

Data Protection
- I understand the personal data on this form (“Personal Data”) will be used by the Company to ascertain my health and physical health, to identify and put parameters in place to deal with any of my medical issues and for the contractual purpose of my employment.
- I understand that the Personal Data will be retained by the Company for the tenure of my employment.
- I understand that my Personal Data will also be used for administrative purposes in relation to my employment.
- I understand that if I do not provide my Personal Data the Company cannot proceed with my application of employment.
By selecting below, I consent to the use of my information as stated above.
Please select*

I consent to the use of my personal information for the purpose and on terms set out above.
Should be Empty:

	Yes	No
Bronchitis, asthma, T.B., or any other chest trouble
High blood pressure, pain in chest, or any heart condition
Nervous or mental trouble
Epilepsy, fainting or blackouts
Giddiness or headaches
Diabetes
Indigestion, gastric or duodenal ulcer or any other gastro-intestinal condition or bowel disorder
Dermatitis or other skin disease
Arthritis, rheumatic fever, rheumatism or gout
Liver, kidney, bladder trouble or jaundice
Anaemia or enlarged glands
Rupture. If yes, do you wear a truss?
Varicose veins
Do you have or have you at any time suffered from any illness of the neck and/or back?
Any other illness, accident or injury?

Application for Employment