<p> Drilcorp Ltd</p><p>APPLICATION FORM</p><p>Position applied for:</p><p>Closing date:</p><p>Please complete this form in ink</p><p>1. Title 2. Gender on Birth Certificate: (Mr/Mrs/Miss/Ms/Other): 3. Surname:</p><p>Forname(s):</p><p>4. Marital Status:</p><p>5. Address:</p><p>Post Code:</p><p>6. E-mail Address:</p><p>7. Home Telephone:</p><p>Work Telephone:</p><p>Mobile Telephone:</p><p>8. NI Number:</p><p>9. General</p><p>Do you hold a current clean driving licence? Yes * No * If NO please give details:</p><p>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:</p><p>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?</p><p>If YES please give details:</p><p>Do you consider yourself to Yes * No * have a disability?</p><p>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.</p><p>10. Education and Training (Please include dates)</p><p>School / College / etc Qualifications Obtained Grade 11. Professional Membership and Qualifications (Please include dates)</p><p>College / University / etc Qualifications Obtained Grade</p><p>12. Training Courses (Please include dates)</p><p>Name and Details of Course Course Results (First Aid, Health and Safety etc.)</p><p>13. Employment History</p><p>List below name of Present / Previous* Employer (*please delete as appropriate)</p><p>Name and address of Employer From: To: Job Title:</p><p>Salary: £ Hour/Week/Month/Year Telephone No.: Notice Required:</p><p>Main Duties and Responsibilities:</p><p>Reason For Leaving (or reason why left):</p><p>Please list ALL positions held, most recent first, identifying any periods of unemployment</p><p>Name and Address Position Held Date Reason for Leaving of Employer and Grade (If any) From To</p><p>Continue on separate page if necessary</p><p>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.</p><p>Signed……………………………………………………………. Date…………………………………………</p><p>14. Personal References</p><p>Please give details of two people (not relatives) we could approach for references</p><p>Name: Name:</p><p>Address: Address: Post Code: Post Code:</p><p>Telephone No.: Telephone No.:</p><p>15. Other information</p><p>Please outline any skills and experience you have gained through paid employment and other work activities and interests.</p><p>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…………………………………………</p><p>For office use only</p><p>Date of interview: Interviewer(s):</p><p>Successful: YES / NO Start Date: Department:</p><p>Supervisor: Job Title:</p><p>Salary: £ Hour/Week/Month/Year Signed:</p><p>16. Monitoring Information</p><p>Please indicate by marking White Asian appropriate box: British Asian British</p><p>Irish Indian</p><p>Other Pakistani</p><p>Mixed Bangladeshi</p><p>White/Black Caribbean Other Asian</p><p>White/Black African Other Ethnic Group</p><p>White/Asian Chinese</p><p>Other mixed Other Ethnic Group</p><p>Black Don’t Know</p><p>Black British Other (please specify)</p><p>Black African</p><p>Black Caribbean</p><p>Other Black</p>