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PLEASE RETURN COMPLETED FORM TO ABOVE ADDRESS
Please complete form in BLOCK CAPITALS

SECTION 1
Personal Details
Full Name
Telephone No
D.O.B
(evidence may be needed)
 Sex:
Female Male
Marital Status
Married Co-habiting Single
Dependants
Yes No
other nationalities Do you require a work permit?
Yes No
Religion
Email Address
Next of Kin
(to be specified in case of emergencies)
Name:
Address:
Tel No (Day) (Evening):

SECTION 2

Tell us about your Practical Experience which makes you suitable for the job

Please show details and dates of training courses you have attended: (e.g. Computers, Accounting, NVQ etc)
SECTION 3
Employment History
Please give details of ALL employment for at least 5 years.  Begin with your present or most recent job. 
(Continue on a separate sheet if required)

Name & Address of Employer Position(s) Held & Duties Performed Date (From/To) Reason For Leaving
1 (Most Recent) / /
to
/ /
2 (Most Recent) / /
to
/ /
3 (Most Recent) / /
to
/ /
4 (Most Recent) / /
to
/ /
5 (Most Recent) / /
to
/ /
SECTION 4
References
Please give the names and addresses of three people, one of which MUST include your present or most recent employer, whom we may approach for a reference

1: Name


 Position:

Address:



Tel No:



Known me for:
2: Name


 Position:

Address:



Tel No:



Known me for:
3: Name



 Position:

Address:



Tel No:



Known me for:
SECTION 5
General Information
Do you hold a current driving licence?
Yes No
If yes, do you drive an
Automatic Manual
Do you have a PC available?
Yes No
National Insurance Number:
SECTION 6
Health Declaration
Height  Foot    Inches Weight  
Date of last medical examination / / Date of last dental check-up
 / /
Do you Smoke
Yes No
No. of cigarettes per day
Do you drink alcohol
Yes No
No of units per week
Identifying Marks or Scars

If you have attended hospital as an in-patient or outpatient in the last 5 years, please give details:
Have you eve undergone tests for HIV?
Yes No
Result
SECTION 7
Inoculations
Have you ever been inoculated against any of the following?

(Tick as appropriate) * Yes * Date No *
German Measles / /
Hepatitis B / /
Polio / /
Tetanus / /
Tuberculosis / /
Other (specify) / /

DECLARATION
I certify the above information is correct and I hereby give permission to TRINITY DENTAL AGENCY to request a further report from my G.P. for declaration if required.

GP: Tel No:
Address:
Signed (by you, the applicant): Date: / /
SECTION 8
Your Work References

Please indicate WHEN you would like to work.  Please tick ALL the relevant boxes.

Full Time  
Days Mon – Fri
Part-Time  
Evenings Mon – Fri
Evenings Sat – Sun
Times
From when are you available to start work?
Do you have any holidays booked?
SECTION 9
Rehabilitation of offenders Act 1974

By virtue of the Rehabilitation of offenders Act 1974 (exceptions) order 1975, the provision of section 4.2 of the rehabilitation of offenders act 1974 do not apply to any employment which is concerned with the provision of care services.

Your answers to the following question should include any "spent" convictions. This may or may not affect your application for this employment.

DOH Circular (88/9) protection of children and POVA, requires us to carry out enhanced C.R.B checks for agency staff whose assignments will give them substantial access to children or adults.

Have you ever been convicted of a criminal offence?
 If yes, please give details on a separate sheet
Yes No
DOH Circular (88/9) Protection of Children requires us to carry out checks on Police records for agency staff whose assignments will give them substantial access to children.

Do you agree that such checks may be made concerning you, if required?
Yes No
SECTION 10   
Declaration
The information I have given in this application form is, to the vest of my knowledge, complete and accurate in all aspects.

I understand that knowingly giving false information will disqualify me from registration with this agency.

Name:  
Signed: Date: / /
Position Applied For:  

Trinity Dental Agency aims to be an equal opportunities employer and we select solely on merit, irrespective of race, sex disability etc.  In order to monitor the effectiveness of our equal opportunities policy, we request all applicants to provide us with the following information:
 
Please note: Ethnic minority questions are not about nationality, place of birth or citizenship.  They are about colour and broad ethnic groups – UK citizens can belong to any of the groups indicated.

Please tick appropriate category:

Bangladeshi Black other (please specify) Other (Please specify)
Black African Chinese Pakistani
Black Caribbean Indian White
Where did you hear about us?
Any other information you would like to add:
FOR OFFICIAL USE ONLY
Work Permit Expiry Date: / /
Passport Number:
Passport Date of Issue: / / Passport Expiry Date: / /
Known usage restrictions (if any):
 
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