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Application for Full-Time Contractual Work (Self-Employed)
Note to the Applicant
To ensure our policy on providing equal opportunities, this form has been designed so as to
exclude as much potentially discriminating information as possible. Please complete all sections
of this application form clearly.

Guidance notes to some of the questions are included on the final page.

Position Applied for:

PART 1: PERSONAL DETAILS (Confidential)

Title: Surname:

Forename(s):
City:
Post code:

Telephone No.: Mobile No:

Email: Preferred method of contact:

GENERAL

Do you have any unspent criminal convictions? If yes,

please see guidance notes.
Where did you hear of this vacancy?

Period of notice required to terminate present employment:

PART 2: EDUCATIONAL & PROFESSIONAL QUALIFICATIONS

You may need to show certificates if invited for interview.

Qualification: Result:

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PART 3: EMPLOYMENT HISTORY

(Please start with the most recent)

Dates
employed
from & to
Employers’
Title of (mth/yr) Brief description of duties Reason for leaving
name and
post: (Dates are and salary (or wishing to leave)
address:
required for
verification
purposes)

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PART 4: SUPPORTING INFORMATION

[Please use this box to demonstrate how you meet the person specification criteria in the job description.]

[Please use this box to explain why you want to work for Publitrad]

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REFERENCES
Please provide the names and addresses of two referees (excluding relatives), one of which must
be your latest employer, or if this is your first job since leaving education, your course tutor.

Name: Name:

Job title: Job title:

Telephone Number:
Telephone Number:
Email: Email:

Address (including company name if a Address (including company name if a

previous employer): previous employer):

(this is my current employer and I would prefer

them not to be contacted )

Postcode: Postcode:

DATA PROTECTION
By signing and returning this form, you consent to the organisation using and keeping information
about you relating to your application and future contract work. Such information may include
data relating to your health, ethnic origin and other sensitive data. Data held concerning you will
be retained for a period of 6 months in the event of your application being unsuccessful. If your
application is successful, the form will be retained and will form part of the organisation’s
personnel records.

In either case, data will be retained in a secure place and will not be disclosed to any third party
without your consent, except when the organisation is required by law to disclose such
information.

DECLARATION
By signing below I confirm that all the information given on this form is complete and true to the
best of my knowledge and belief. I am aware that a deliberate attempt to falsify information will
disqualify my application or may lead to termination of the contract.

Signature: Date:

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GUIDANCE NOTES TO HELP YOU COMPLETE THIS APPLICATION FORM

Criminal Offences
Please send with this Form any details of unspent convictions in a separate envelope to
“The Senior Manager” and marked ‘Private and Confidential.’

It is important that you disclose any unspent criminal convictions you may have. This will
not necessarily affect your application as we consider each case on its own merits. Failure
to disclose any convictions may affect your employment if it later becomes known to us.

Employment History
Provide details of all employment/training since leaving full time education and continue on
a separate sheet if necessary. Dates should be “from” and “to.”

Qualifications
Please provide information on any qualifications you have gained. You may be required to
provide documentary evidence (e.g. certificates) at interview stage.

Supporting information
This section is very important and you should use this to highlight why you consider
you are suitable for employment with us in the position applied for. You may refer to
any voluntary work or your interests/hobbies. Please let us know why you specifically
want to work for Publitrad.

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Equal Opportunities Monitoring Form

We are committed to recruiting, retaining and developing a workforce that reflects at all grades
the diverse communities that we serve. It is vital that we monitor and analyse diversity
information so that we can ensure that our HR processes are fair, transparent, promote
equality of opportunity for all staff, and do not have an adverse impact on any particular group.
Your cooperation in providing us with accurate data will ensure that we, not only meet our
legal obligations, but even more importantly will result in us designing and applying policies
and processes that attract and retain a diverse, talented and motivated workforce. Any
information provided will be treated as strictly confidential and will be used for statistical
purposes only. If used during the recruitment process, it will not be seen by anybody directly
involved in the selection process. No information will be published or used in any way which
allows any individual to be identified.

Gender:

Male  Female 

Are you married or in a civil partnership?

Yes  No  Prefer not to say 

Age 16-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Prefer
not to say 

How would you describe your national identity?

English Welsh Scottish Northern Irish 

British Other Prefer not to say 

What is your ethnicity?

Ethnic origin categories are not about nationality, place of birth or citizenship. They are about
the group to which you as an individual perceive you belong. Please indicate your ethnic origin
by ticking the appropriate box
White
English  Welsh  Scottish  Northern Irish 
Irish  Gypsy or Irish Traveller  Other White background 
Mixed/multiple ethnic groups
White and Black Caribbean  White and Black African 
White and Asian  Any other mixed background 
Asian/Asian British
Indian  Pakistani  Bangladeshi Chinese 
Any other Asian background 
Black/ African/ Caribbean/ Black British
African  Caribbean 
Any other Black/African/Caribbean background
Other ethnic group
Arab  Any other ethnic group 

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Prefer not to say 

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Do you consider yourself to be disabled? Yes No Prefer not to say 
Any information you provide here will be used for monitoring purposes only – if you need a
‘reasonable adjustment’, then please follow the additional separate process. We will take
reasonable steps to meet your particular needs.

What is your sexual orientation?

Heterosexual/straight 
Gay woman/lesbian 
Gay man 
Bisexual 
Other 
Prefer not to say 

What is your religion or belief?

No religion Buddhist  Christian 

Hindu  Jewish  Muslim 
Sikh  Any other religion Prefer not to say 

Do you have caring responsibilities? If yes please tick all that apply

None 
Primary carer of a child/children (under 18) 
Primary carer of disabled child/children 
Primary carer of disabled adult (18 and over) 
Primary carer of older person (65+) 
Secondary carer 
Prefer not to say 

By completing this form you have helped us better understand how we, as an employer,
ensure equality of opportunity for all.

Thank you for completing this form.

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