mind yourselfApplication Form

Please note that we keep this information confidential.

1 PERSONAL DETAILS

First Name Last Name

Address Line 1

Address Line 2

Address Line 3

Mobile Phone Landline Phone

Email Address Other Email

2 APPLICATION DETAILS

Job Title

Job Location

Where did you see the role advertised?

3 AVAILABILITY

When are you available to start?

4 SALARY EXPECTATIONS

What are your salary expectations?

5 VISA/PERMITS

Are you eligible to work in the UK?

6 WORK HISTORY

Please list details of your previous roles starting with your current/most recent role.

Position 1 (Most Recent)

Employer Location

Title Supervisor & Title

Date From / To Reason for Leaving

Salary Other Benefits

Responsibilities & Achievements [please expand as necessary]:

Position 2

Employer Location

Title Supervisor & Title

Date From / To Reason for Leaving

Salary Other Benefits

Responsibilities & Achievements [please expand as necessary]:

Position 3

Employer Location

Title Supervisor & Title

Date From / To Reason for Leaving

Salary Other Benefits

Responsibilities & Achievements[please expand as necessary]:

Position 4

Employer Location

Title Supervisor & Title

Date From / To Reason for Leaving

Salary Other Benefits

Responsibilities & Achievements[please expand as necessary]:

Other Employment (Please use additional paper to list other employment)

From To Title Employer Location

7 EDUCATION & TRAINING

Degrees, Diplomas, Certificate, Licences, Training Courses (List additional information on a separate page)

From To Course Qualification Institution Location Grade

Please list any relevant organisations or professional bodies of which you are a member

8 TELL US WHAT YOU THINK

1. Tell us how you think you meet the job specification? (max 200 words)

2. Tell us about your previous experience in a similar role (max 200 words)

9 BUSINESS APPLICATIONS

Please indicate skill level. (Basic / Intermediate / Advanced)

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Microsoft Outlook

Other Email Systems

Other Systems

10 RETENTION OF YOUR RECORDS

This form will be used by Mind Yourself to help assess your suitability for employment and may be used for appropriate checks. We will retain your application in accordance with Irish employment law. If your application on this occasion is unsuccessful, we may retain your records in case other opportunities arise in the future which we think may be of interest to you. If you do not wish us to do so; please tick this box.

11 CRIMINAL

Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974, by virtue of the Exceptions Order 1975 as amended by the Exceptions (Amendment) Order 1986, which means that convictions that are spent under the terms of the Rehabilitation of Offenders Act 1974 must be disclosed, and will be taken into account in deciding whether to make an appointment. Any information will be completely confidential and will be considered only in relation to this application.

In addition you are required to submit to a Criminal Records Bureau check. Any standard or enhanced disclosure made by the CRB/SCRO will remain strictly confidential.

Have you ever been convicted in a Court of Law and/or cautioned in respect of any offence? YES/NO (delete as required)

If YES, please give details

12 REFEREES

Name Name

Address Address

Telephone No Telephone NoEmail address Email AddressRole RoleRelationship to you Relationship to

you

13 DECLARATION

I confirm that the information provided on this form and any attachments are accurate and complete. I understand that any misleading statements are sufficient for termination of any agreements made. I understand that any information later discovered to be incorrect may result in the termination of any agreements made. I agree that any future offer of employment is subject to satisfactory references, health clearance, and having the required work permit.

Name Signature Date

14 MIND YOURSELF

We are Mind Yourself. We work to improve the health and wellbeing of the Irish community in London. We recognise and celebrate the diversity of Irish identity. We are equal opportunity employers