Job Application Form – Lordam Support Services

APPLICATION FOR EMPLOYMENT

POSITION APPLIED FOR

If you are applying from outside the UK please tick this box

Surname

First name

Middle name

Address

Telephone Number

Email Address

National Insurance Number

Are you 18+ years of age?

Yes No

Do you require a work permit to be employed in the UK?

Yes No

Name of your next of kin

Next of kin - relationship to you?

Next of Kin Telephone Number

Next of Kin Email

Next of Kin Address

Upload your CV

Work History (CURRENT/LAST EMPLOYER) Do you have previous work experience?

Yes No

How many years of work experience do you have in total?

Employer (1)

Address of employer

Position held

Employer (2)

Address of employer

Position held

Upload your Professional Qualification Certifications

Professional Qualifications held:

Professional Registration(s):

NMC Pin (if applicable):

Expiry Date:

UNIVERSITY/ COLLEGE:

QUALIFICATION (S) OBTAINED:

Start Date

End Date

YOUR APPLICATION FOR THIS POSITION

OUTSIDE INTERESTS

DISABILITY DISCRIMINATION ACT 1995 - Do you consider yourself to be disabled under the ‘Disability Discrimination Act’?

Yes No

If ‘YES’ are there any adjustments that you think we could make to overcome a disability in relation to the essential requirements of this job?

Yes No

If ‘YES’, please provide further details:

REFERENCES

Referee 1 - MUST be Current or Most Recent Employer

Please state if we may obtain this reference prior to interview

Yes No

Referee 2 - MUST be Current or Most Recent Employer

Please state if we may obtain this reference prior to interview

Yes No

Omission of information in your references will slow our progress in obtaining them

INTERVIEM ARRANGEMENTS -If you need any particular arrangements to be made in order for you to be interviewed for this position at our premises, please give details

Rehabilitation of Offenders Act 1974 Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act (Exemptions) 1973. Applicants are, therefore, not entitled to withhold any information about convictions, for which other purposes, are ‘spent’ under the provisions of the Act. In the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be treated in the strictest confidence and will only be considered in relation to posts for which the order applies.

Do you have any criminal convictions to disclose? (delete as applicable)

Yes No

If YES, please give details:

I confirm that to the best of my knowledge and belief the information I have given on this form is true and correct.

Yes

Full name

Date

Data Protection: The information provided on this form will be used by us for the purposes of assessing your application
and, if your application does not result in your being employed by us, will be retained only for so long as is necessary. If
you are employed by us, the information will form part of your personnel file and may be processed for any purpose in
connection with your employment

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Opening Hours:
Monday – Friday 8am – 9pm

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Phone: +447478270126, +447463480585
Email: info@lordamservices.com, referral@lordamservices.com

Office Address: Enterprise Centre, David Lane, Basford, Nottingham

NG6 0JU.

Placement: Preston Road, Wembley, London HA9 8NJ.