Eyears Staff Application

Personal Details

Title *

First Name *

Surname *

Address *

Post Code *

Tel *

Mobile

E-Mail *

Confirm E-Mail *

DOB *

National Insurance No.

Emergency Tel

Next of Kin and relationship

Address

Type of work you are looking for?

Interested in which location? *

Where are you currently working?

How did you hear about us? *

Do you drive?

Yes No

Do you have access to drive a car?

Yes No

Qualifications

Please enter your qualifications into the fields below.

Qualification #1

Title

Where Obtained?

Date From - To

Qualification #2

Title

Where Obtained?

Date From - To

Qualification #3

Title

Where Obtained?

Date From - To

Qualification #4

Title

Where Obtained?

Date From - To

Qualification #5

Title

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 tutor and last 2 placements.

Referee 1

Contact Name

Position

Address

Telephone No.

E-Mail

Referee 2

Contact Name

Position

Address

Telephone No.

E-Mail

Referee 3

Contact Name

Position

Address

Telephone No.

E-Mail

Referee 4

Contact Name

Position

Address

Telephone No.

E-Mail

Referee 5

Contact Name

Position

Address

Telephone No.

E-Mail

Employment Details

Contact details of your last or current Employer.

Name

Position Name

Address

Job Title

Salary

(plus any benefits)

Date of starting

(dd/mm/yyyy)

Reasons for leaving

Notice period

Job Description

(daily duties, activities & areas of responsibility )

Prior Employment Details

Employer #1

Employers name

From - to

Employed As

Reason for leaving

Employer #2

Employers name

From - to

Employed As

Reason for leaving

Employer #3

Employers name

From - to

Employed As

Reason for leaving

Employer #4

Employers name

From - to

Employed As

Reason for leaving

Employer #5

Employers name

From - to

Employed As

Reason for leaving

Bank Details

Bank Name

Bank Address

Account Name

Account Number

(8 digits)

Ref Number

Sort Code

(6 digits)

Building Society Roll No

(Max 20 digits)

Training

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

Moving and handling

Date

Venue

Health and safety

Date

Venue

Adult / Newborn CPR

Date

Venue

Food Hygiene

Date

Venue

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 I Do Not Agree

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

Medical Fitness to Work

Do you have any physical or health conditions that impact your capacity to work as required by Education Health Standards (England) 2003 Regulations? *

Yes No

Eligibility to work within the UK

Are you legally eligible to work in the UK?

Yes No

Do you have any endorsements on your passport which limit your stay or length of employment in the UK?

Yes No

Do you require a work permit?

Yes No

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.

Do you have any, or any pending convictions, cautions, reprimands or final warnings, which would not be filtered in line with current guidance? *

Yes No

If Yes, please provide more information on the nature of the convictions, cautions, reprimands or final warnings and the dates of any convictions

DBS Disclosure

Eyears check, record & monitor the DBS status of all applicants where it is warranted or legislated. This will either take form of a brand new DBS check or utilisation of the DBS Update Service. Full details of the service can be found HERE. Eyears will check at regular intervals to ensure this status is still valid.

By submitting your application to Eyears you agree to this process and procedure prior to offer of employment.

I accept and understand the above statement *

Do you have a DBS 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 No

If so which agencies did you register with?

Agency #1

Agency name

From - to

Reasons for joining

Reason for leaving

Agency #2

Agency name

From - to

Reasons for joining

Reason for leaving

Agency #3

Agency name

From - to

Reasons for joining

Reason for leaving

Agency #4

Agency name

From - to

Reasons for joining

Reason for leaving

Agency #5

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 your CV and append it to the application form

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