Position applied for *

Title *

First name *

Surname *

Full address *

Postcode *

Home telephone no *

Mobile telephone no

Work telephone no

Email address

Can we contact you at work?Yes | No

National Insurance number

If you do not have a national insurance number, please supply details of any right to work in the UK and/or work permit currently held including number and expiry date.

Herefordshire Housing is committed to the employment and career development of disabled people. To demonstrate this we use the Positive about Disabled People symbol. As a symbol user, we guarantee to interview anyone with a disability, within the meaning of the Disability Discrimination Act 1995 (amended 2005), whose application meets the essential criteria for the post being advertised. The evidence you provide on the application form will be used to determine if the criteria has been met.

A person has a disability for the purpose of the Disability Discrimination Act 1995 (amended 2005) if he/she has a physical or mental impairment which has a substantial and long term effect on his/her ability to carry out normal day-to-day activities. Please contact the Human Resources Team on 01432 384160 if you require further clarification on this.

Do you have a disability, long term illness or health problem (which has lasted or will last 12 months or more) which limits daily activities or the work you can do? Or have you been diagnosed with a condition such as HIV, cancer or multiple sclerosis which is deemed to be covered from point of diagnosis? *Yes | No

If you have a disability and would like to be considered under the scheme please tick the declaration below.

I confirm that I am a disabled person within the meaning of the Disability Discrimination Act 1995 (amended 2005). I understand that making a false declaration of disability to obtain a guaranteed interview could subsequently invalidate any contract of employment. *Yes | No

If you have been convicted of any offence, you must disclose it, unless it is 'spent' under the Rehabilitation of Offenders Act 1974. However, having a criminal record will not necessarily bar you from employment with us. Any information revealed here or as a result of a disclosure will be considered in the light of the responsibilities of the job.

If the job you are applying for involves access to children, the vulnerable or elderly then you MUST state any convictions, bind over orders or cautions whether current or spent. In the event of employment, any failure to disclose these and/or pending investigations could result in disciplinary action and/or dismissal. All jobs with access to children, the vulnerable or elderly will be subject to a Criminal Records Bureau Disclosure.

Please give details below of:

A) Any convictions or charges outstanding of all offences, or charges outstanding in relation to alleged offences, including driving offences. Parking offences need not be declared. If you inadvertently disclose a conviction, which is regarded as 'spent', it will be ignored.

B) Any disqualification from driving or performance of professional duties.

This information will be treated as confidential and will only be used for monitoring purposes. The information that you provide on this form will be kept in accordance with the Data Protection Act 1998 and used only for the purpose of equality and diversity monitoring.

1. What is your date of birth * (dd/mm/yyyy)

2. Are you *Male | Female

3. How would you describe your ethnic origin?

   White

   	British
   	Irish
   	Other White Background (please complete field below)

   Mixed

   	White and Black Carribbean
   	White and Black African
   	White and Asian
   	Other Mixed Background (please complete field below)

   Asian or Asian British

   	Indian
   	Pakistani
   	Bangladeshi
   	Other Asian Background (please fill in field below)

   Black or Black British

   	Caribbean
   	African
   	Other Black Background (please fill in field below)

   Chinese or any other Ethnic group

   	Romany/Gypsy
   	Traveller
   	Chinese
   	Other Ethnic Group (please fill in field below)

   If you ticked one of the 'other' options, please specify

4. Do you consider yourself to have a disability? *Yes | No

   (By this we mean a condition that has a long term and substantial effect on your ability to carry out normal day to day activities)

   If yes is it

   	Physical
   	Learning Disability or Difficulty
   	Hearing Impairment
   	Mental Health
   	Visual Impairment
   	Progressive/Chronic Illness e.g. MS, cancer
   	Other

   If you ticked other, please specify

5. How would you describe your religion?

   	Christian
   	Buddhist
   	Hindu
   	Muslim
   	Jewish
   	Sikh
   	Other
   	Prefer not to say

6. How would you describe your sexuality?

   	Hetrosexual
   	Gay Man/Lesbian
   	Bisexual
   	Prefer not to say

7. How did you find out about this vacancy?

   	Hereford Times
   	Our website
   	Job centre
   	Other newspaper/journal (please specify)
   	Online (please specify)
   	Other (please specify)

   If you ticked other or online, please specify

Please give contact details of two referees, one of whom should be your present or most recent line manager. References will be taken up for short listed candidates only. Please note personal references should not be used.

1. Reference One

   Title *

   Name *

   Job Title *

   Address *

   Postcode *

   Telephone no

   Email address

   Relationship to you *

   Please tick the box provided if you do not wish us to contact this referee without specific consent from you?

   Require consent to contact

2. Reference Two

   Title *

   Name *

   Job Title *

   Address *

   Postcode *

   Telephone no

   Email address

   Relationship to you *

   Please tick the box provided if you do not wish us to contact this referee without specific consent from you?

   Require consent to contact

Name of employer / organisation *

Job title *

Full address *

Postcode *

Date employed (From) *

Date employed (To)

To whom immediately responsible *

Salary or other remuneration details

Reason for leaving (if applicable)

Notice required

Brief description of duties *

Please provide details of your previous employment beginning with your most recent first. You can include any relevant voluntary or unpaid work that you may have done.

Other relevant training or work related skills (for example computer skills, languages, shorthand etc.)

You will be required to provide evidence of your qualifications at interview

Do you hold a full driving licence? *Yes | No

Do you have use of a car? *Yes | No

Are you undertaking any course of study at present? *Yes | No

If Yes: College

If Yes: Course

If Yes: Completion date

Do you have membership of any professional bodies? *Yes | No

If so, please give details?

Please state the number of days sickness (or for any other absence) in the last 2 years, excluding any agreed leave.

Are there any dates on which you would NOT be able for interview?

Are you known or related to any employee of the Company? *Yes | No

If yes, please give details

In no more than 800 words please give your reasons for applying for this post and provide additional information and examples of how your knowledge, skills, experience and training meet each element within the person specification for this position. *

The information from this application may be processed for the purposes registered by the employer under the Data Protection Act 1998.

I hereby give consent for Herefordshire Housing Ltd. to process the data supplied in this application form for the purpose of recruitment and selection.

I also declare that, to the best of my knowledge and belief, the information I have given in this application is true and accurate. I understand that providing misleading or false information may disqualify me from appointment or may result in dismissal. *Yes | No