<p> Application Form</p><p>STRICTLY CONFIDENTIAL - APPLICATION FOR EMPLOYMENT WITH AGE UK ISLE OF WIGHT</p><p>Registered Address: 147 High Street, Newport, Isle of Wight PO30 1TY</p><p>Telephone: 01983 525282</p><p>Email: [email protected]</p><p>Important Information: a) Please answer all questions b) Please complete clearly in black ink or type c) Your completed Application Form and Equal Opportunities Monitoring Form to be received on or before the closing date and should be emailed where possible to: [email protected] , or posted to the address above d) Offers of employment are subject to receipt of satisfactory references, your proof of right to work in the UK, and if appropriate to the job role a Disclosure & Barring Service check e) If offered employment, you will be required to complete a Medical Questionnaire f) If offered employment, you will be required to provide copies of your Driving Licence, Vehicle Insurance showing business use and MOT Certificate if appropriate to your job role</p><p>POSITION APPLIED FOR:</p><p>1. PERSONAL INFORMATION</p><p>Surname Title</p><p>First Name</p><p>Address (including Postcode)</p><p>Telephone (home) Page 1 of 6 Telephone (mobile)</p><p>Email</p><p>2. CAR OWNER Yes / No Do you have a full current driving licence? (delete as appropriate) Yes / No (delete as appropriate) If yes please provide details Do you have any endorsements? </p><p>Yes / No (delete as appropriate) Where staff are required to use a car as part of their role, Are you a car owner / have daily access to a car? they are annually required to provide copies of their driving licence, MOT certificate, and vehicle insurance showing business use</p><p>3. PREVIOUS EMPLOYMENT WITH AGE UK ISLE OF WIGHT Yes / No (delete as appropriate) If yes please give brief details Have you worked for Age UK before? </p><p>YES / NO Delete as appropriate Have you applied for employment with Age UK If yes please give brief details before? </p><p>4. PRESENT OR LAST EMPLOYER Name of current or most recent employer</p><p>Address</p><p>Telephone number</p><p>Position held</p><p>Brief description of duties</p><p>Dates of employment Reason for leaving</p><p>Current / leaving Application Form salary Notice period</p><p>5. PREVIOUS EMPLOYMENT (in chronological order, giving exact dates) Dates Name & Address of Employer Post Held & Brief Description of Duties</p><p>6. EDUCATIONAL BACKGROUND (in chronological order) Name Examinations Passed & Grades </p><p>Secondary School</p><p>College / University</p><p>Other relevant training Page 3 of 6 7. PUBLIC DUTIES (Please give details of any public service duties which you are required to perform e.g. JP, member of local authority, etc.)</p><p>8. CRIMINAL CONVICTIONS Yes / No (delete as appropriate) Have you ever been convicted of If yes please give brief details a criminal offence?</p><p>9. HOW DID YOU HEAR ABOUT THE POST?</p><p>10.REFEREE DETAILS (1) (If possible please list referees from two latest employers)</p><p>Name</p><p>Position / Relationship to you</p><p>Address</p><p>Email address</p><p>Telephone number</p><p>REFEREE DETAILS (2)</p><p>Name</p><p>Position / Relationship to you</p><p>Address</p><p>Email address</p><p>Telephone number Application Form</p><p>11.SUPPLEMENTARY INFORMATION Continue on an extra sheet if necessary. This is your opportunity to state why you are interested in this post, and what skills and experience you would bring to it. Please confirm whether you are applying for this position full time or as a job share. If job share please confirm the maximum hours you are able to work.</p><p>Page 5 of 6 Supplementary Information (continued)</p><p>12.DECLARATION I understand that the information given on this form is true and correct and understand that any deception could result in instant dismissal if appointed. I understand that these details are held in confidence by Age UK IW, for the purposes of ongoing personnel administration and payroll administration in compliance with the Data Protection Act 1998. I undertake to notify Age UK IW immediately of any changes to the above details.</p><p>Print name</p><p>Signature</p><p>Date</p>