Please Complete This Form in Ink

Drilcorp Ltd

APPLICATION FORM

Position applied for:

Closing date:

Please complete this form in ink

1. Title 2. Gender on Birth Certificate: (Mr/Mrs/Miss/Ms/Other): 3. Surname:

Forname(s):

4. Marital Status:

5. Address:

Post Code:

6. E-mail Address:

7. Home Telephone:

Work Telephone:

Mobile Telephone:

8. NI Number:

9. General

Do you hold a current clean driving licence? Yes * No * If NO please give details:

Have you ever been convicted of a criminal offence? Yes * No * (Other than a spent conviction under the Rehabilitation Offenders Act 1974) If YES please give details:

Are you able to: Work anywhere in the UK? Yes * No * Work overtime if required? Yes * No * Work anyway from home if required? Yes * No * If you answered NO to any of the above please give details Do you have any physical/medic al condition which could limit your Yes * No * ability to perform the particular job for which your applying?

If YES please give details:

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

If YES please give details, including how with the provision of aids or modification we would be able to assist you carrying out the duties of the post applied for.

10. Education and Training (Please include dates)

School / College / etc Qualifications Obtained Grade 11. Professional Membership and Qualifications (Please include dates)

College / University / etc Qualifications Obtained Grade

12. Training Courses (Please include dates)

Name and Details of Course Course Results (First Aid, Health and Safety etc.)

13. Employment History

List below name of Present / Previous* Employer (*please delete as appropriate)

Name and address of Employer From: To: Job Title:

Salary: £ Hour/Week/Month/Year Telephone No.: Notice Required:

Main Duties and Responsibilities:

Reason For Leaving (or reason why left):

Please list ALL positions held, most recent first, identifying any periods of unemployment

Name and Address Position Held Date Reason for Leaving of Employer and Grade (If any) From To

Continue on separate page if necessary

I hereby give permission for Drilcorp Ltd to contact the employer(s) listed above concerning prior work experience. If there is a particular employer(s) you do not wish us to contact please indicate which one(s) by putting an ‘X’ in the box.

Signed……………………………………………………………. Date…………………………………………

14. Personal References

Please give details of two people (not relatives) we could approach for references

Name: Name:

Address: Address: Post Code: Post Code:

Telephone No.: Telephone No.:

15. Other information

Please outline any skills and experience you have gained through paid employment and other work activities and interests.

The facts set forth in this application for employment are, to the best of my knowledge, true and complete. I understand that any false declaration may result in employment, should it be offered, being terminated immediately. Signed……………………………………………………………. Date…………………………………………

For office use only

Date of interview: Interviewer(s):

Successful: YES / NO Start Date: Department:

Supervisor: Job Title:

Salary: £ Hour/Week/Month/Year Signed:

16. Monitoring Information

Please indicate by marking White Asian appropriate box: British Asian British

Irish Indian

Other Pakistani

Mixed Bangladeshi

White/Black Caribbean Other Asian

White/Black African Other Ethnic Group

White/Asian Chinese

Other mixed Other Ethnic Group

Black Don’t Know

Black British Other (please specify)

Black African

Black Caribbean

Other Black