In confidence

Application Form

Leicestershire Leicester and Rutland Headway
Application for the post of: Community Outreach Worker

Privacy notice: This form collects sensitive personal information. This site retains none of that information after submission.

1. Personal Details

Surname

Date of birth

First names

Email address

National Insurance number

Address

Tel. no. (day)

Tel. no. (evening)

Postcode

Mobile

Do you have a full driving licence? Yes No

Do you have a car? Yes No

Are you registered disabled? Registered disabled Unregistered disabled Not disabled

2. Previous Education

School/College/University	From	To	Qualifications	Grades

3. Specialist/Professional Training or Qualifications

Organising body	Details of course	Duration	From	To

4. Non-Qualification Courses Attended

Organising body	Details of course	Duration	From	To

5. Present Employment

Post held

Salary

Hours/week

Date of appointment

Employer's name and address

Brief summary of your duties

Reason for seeking new employment

6. Previous Employment

Employer	Position held	Salary	From	To	Reason for leaving

7. Experience and Skills

Please state why you are applying for this post and what relevant experience or skills support your application.

Interests/Hobbies

8. Health Record for the Past Two Years

How many days' sickness have you taken?

On how many occasions?

Do you have any special requirements to enable you to fill this post?

9. Availability

I am able to fill the post on: Mon Tues Wed Thurs Fri

Availability

Other (please specify)

Annual leave commitments already booked

10. References

Please give details of 2 referees, one of whom should be your current or most recent employer.

Referee 1

Name

Position held

Address

Postcode

Tel. no.

Referee 2

Name

Position held

Address

Postcode

Tel. no.

11. Right to Work Declaration

I confirm that the information given above is correct and true to the best of my knowledge and, under the Immigration, Asylum and Nationality Act 2006, I am eligible to work within the UK. This declaration will be treated as part of any Contract of Employment.

I confirm this declaration.

Applicant's full name

Date