Eyears Staff Application

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Eyears Staff Application

Please take your time to fill out the application as fully as possible, then press send application to send your details to us, and we will get back to you to arrange an interview. If you have a C.V. that you would like to send, please append the document onto the application using the CV Uploader tool.

Personal Details

First name
Surname
Address
Post Code
Tel
Mobile
E-Mail
DOB
National Insurance No.
Emergency Tel
Address
Type of work you are looking for?
How did you hear about us?
Do you drive?	Yes No
Do you have access to drive a car?	Yes No

Personal Qualifications	Where Obtained?	Date from - to

References
Please provide contact details for 3 referees, one of which must be your last or present Employer and should cover 5 years. If you have just left education/college, provide details of your last 3 placements.

Referee 1
Contact Name
Position
Address
Telephone No.
Email Address

Referee 2
Contact Name
Position
Address
Telephone No.
Email Address

Referee 3
Contact Name
Position
Address
Telephone No.
Email Address

Employment Details

Contact details of your last or current Employer.

Name
Position
Address
Job title
Salary (plus any benefits)
Date of starting
Reasons for leaving
Notice period
Brief description of daily duties, activities & areas of responsibility

Prior Employment Details

Employers name	From - to	Employed As	Reason for leaving

Bank Details

Bank
Bank Address
Account Name
Account Number (8 digits)
Ref No.
Sort Code (6 digits)

Training
Please indicate which courses you have attended in the last 12 months.

	Date	Venue
Moving and handling
Health and safety
Adult / Newborn CPR
Food Hygiene

From time to time it may be required to disclose certain information regarding your application to place you into assignments. Please be assured only information that is absolutely necessary will be disclosed. We would appreciate it if you would amend the statement below to declare your wishes. IF you have any concerns, please do not hesitate to contact us.

I Agree

Do Not Agree

To have my information disclosed should it be required in the placement on assignments.

Occupational Health Screen

How many absent days have you had in the last 12 months?
How many incidents of absences have you had in the last 12 months?
Have you ever left employment due to ill health?
Are you currently taking any medication?

Please indicate below if you have ever suffered or currently suffer from any of the following medical conditions or complaints. please indicate on a separate sheet of paper if these have led to absence from work or details of any disability.

	Yes	No	Details
Asthma / Pleurisy / Hay Fever / Chest infections/ Tuberculosis
Heart / Circulation / Blood Pressure
Gastric problems, IBS, kidney or urinary condition
Skin rashes / allergy to food or medication
Thyroid / diabetes / glandular illness
Mental illness. depression or nervous breakdown
Chicken pox / Shingles (varicella)
Migraine / headache / varicose veins / painful periods
Are you registered under the Disabled Persons Act?

Eligibility to work within the UK

	Yes	No
Are you legally eligible to work in the UK?
Do you have any endorsements on your passport which limit your stay or length of employment in the UK?
Do you require a work permit?

Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act 1974 (exception order 75) states that the Act does not apply to any employment which is concerned in the provision of health services, or which is likely to enable the holder to have access to persons in receipt of such services in their duties.

Have you ever been convicted of a criminal offence? (including spent convictions)	Yes	No
If YES, please states the nature of the conviction (s) and date (s) convicted

CRB Disclosure

Do you have a CRB Disclosure?	Yes	No
Disclosure Number:
Date of Disclosure

Working Time Directive

The current limit for working hours within the European Union is 48 hours per week. You are under no obligation to accept work offered to you and will never be instructed to work more than 48 hours per week, however you may choose to do so. Please confirm you have read and understood this information and indicate your desired choice below.
I have read and understood the statement above and..

I Do I Do Not

..wish to work more than 48 hours per week.

Work Preference

Are you or have you ever registered with an employment agency before?	Yes
If so which agencies did you register with?

Agency name	From-to	Reasons for joining	Reason for leaving

Availability For Work

Are you looking for full or part time work?
How many hours per week are you available?
What type of work do you want to do?
Are you aware of our referral scheme?
Is there anywhere you would like to work?
Is there anywhere you do not wish to work?
How far are you willing to travel?
Is there a different type of work you would like to try?

Curriculum Vitae
Browse for you CV and append it to the application form.

Declaration

We may wish to contact you to ask for your opinion or view regarding our services. This may be via telephone, letter, email or other media as available. Please tick here if you do not wish us to contact you regarding this.

We may contact you to work with details of work, via telephone, letter, email or other media available. Please tick here if you do not wish us to contact you regarding this.

By sending this application, I declare the information in this application to be true & correct. I understand that if any of the data is untrue, misleading or I have failed to declare facts, future employment offers may be withheld or removed without notice.

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