Application for Employment
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White Lion Chambers, 44 High Street,
Bedworth, CV12 8NF
References
Please give below the names and addresses of two referees whom we can contact for references. At least
one referee should be your present or most recent employer, (school or college, if a student). Relatives or
partners cannot be accepted as referees. Please note that no offer of employement will be made prior to
receipt of references. We usually apply for references before interview.
1
Name.............................................................................
Address........................................................................
.......................................................................................
.......................................................................................
Telephone...................................................................
Capacity in which referee knows you:
.......................................................................................
May we approach the above prior to interview? YES / NO 		2
Name...........................................................................
Address......................................................................
.....................................................................................
.....................................................................................
Telephone.................................................................
Capacity in which referee knows you:
.....................................................................................
May we approach the above prior to interview? YES / NO
Please state if you are related to any Director or member of staff of the organisation?       YES / NO

If yes, state the name of that person..................................................................................

Health Record
Please indicate the number of days absent due to illness during the last twelve months................................
Are you prepared to undertake a medical examination if necessary?     YES / NO

For our monitoring purposes: Where did you hear about this position? If you saw the position in a
newspaper, please state which newspaper / publication.
(Downloaded from PIA web site)

DECLARATION:
I confirm that the information I have given on this form is correct and complete, and that any misleading
statements may be sufficient reason for cancelling any agreements made. In the event of being shortlisted
for interview, I will be required to complete a declaration of criminal record. Due to the sensitive nature of
the duties the post holder will be expected to undertake, I understand that this declaration will include
details of any criminal convictions, cautions, reprimands, final warnings and any other information that
may have a bearing on my suitability for the post. I understand that an Enhanced Disclosure will be sought
from The Criminal Records Bureau in the event of a successful application.

Signature.....................................................................................Date......................../............./.....................

Due to the large number of applications we receive, if you do not hear from us within 21 days, your application has not been successful on this occasion. Thank you for your interest in our organisation.

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