Telephone: 01268204170 emergency: +447723282311 ADDRESS: Suite 9.2, Cornwallis Business Centre Ltd, Howard Chase, Basildon, Essex, SS14 3BB

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info@jegacareltd.co.uk

Enter your full name

Provide your email address*

Address

Date of Birth

National Insurance Number

Telephone number

Mobile number

Are you subject to Immigration control? YES/ NO (If yes, please provide details)

Are you free to remain and take up employment in the UK?

Do you own a complete & current driving licence?

Do you own a car?

Current or Most Recent Employment including Name & Address of Employer, Job Title, Date From, Date To, Notice period, Grade, Reason for Leaving and Brief description of current or most recent duties:*

Previous Employment History (most recent post first) including Employer, Job title, Salary/ Grade, Date From, Date To and Reason for leaving.*

How many periods of sickness have you had over the last 2 years? *

How many days in total? *

Any gaps in employment?

Education, including Professional Development, e.g NVQ, Open University, etc. Please include Secondary School/College/University, Dates Attended, Qualifications, Dates Obtained.*

Training Courses Attended (most relevant)

Other Skills: Please give details of any other skills relevant to the post applied for.

Comments: Please explain why you have applied for this post, and list any skills that could support your application. application

Leisure Interests: Please tell us about your hobbies, interests, club membership, and other activities.

References (please provide details of two referees, including current/last employer. Please include name, relationship, Address, telephone number and email address.*

Can we take up references before making an offer? YES/NO*

Period of notice in current employment? Do you have any holidays booked? If YES, please give dates:*

Statement of Medical History. Please carefully enter all details in this section. If you are in any doubt, you may wish to consult with your Doctor. Do you suffer or have you suffered from any of the following? Tuberculosis Asthma/Bronchitis Pneumonia Bowel Problems High Blood Pressure Heart disease Neck/Back Injury, Hernia/Rupture Gastric/Duodenal Pleurisy Coughing/Spitting Blood Dysentery/Typhoid Jaundice Hepatitis A, Diabetes Epilepsy Fits/Faints/Blackouts Head Injury Concussion/Giddiness Rheumatism/Arthritis Varicose Veins Migraine, Hepatitis B Hepatitis C Dermatitis Eczema Psoriasis Allergies Mental Illness Depression*

If the answers to any of the ailments are yes, please give details below.

Have you lived outside the UK for longer than 6 months in the last 5 years? YES/NO Place and Country of Residence including dates.

Immunisation & Vaccination History. Please state with dates, whether you have been immunised against any or all of the following. Hepatitis B Tetanus Polio Diphtheria TB/BCG Rubella

Details of your General Practitioner including Name Address Tel No. Reason for last visit

Are there any other health issues you should make us aware of? YES/NO If the answer is YES, please specify:

Have you been hospitalised during the last 5 years? YES/NO If the answer is YES, please specify:

DISABILITY DISCRIMINATION The Disability Discrimination Act 1995 (DDA) protects disabled people. The DDA defines a person as disabled if they have a physical or mental impairment, which has a substantial and long term (ie has lasted or is expected to last at least 12 months) and adverse effect on the person’s ability to carry out normal day-to-day activities. The list below contains examples of the types of impairment. Physical impairment, such as difficulty using your arms or mobility issues which means using a wheelchair or crutches. · Sensory impairment, such as being blind/having a serious visual impairment or being deaf/having a serious hearing impairment. · Mental health condition, such as depression or schizophrenia. · Learning disability, such as dyslexia, or cognitive impairment, such as autism. · Long-standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy. · Other, such as disfigurement.

DECLARATION. I understand and acknowledge that should I knowingly make a false statement in response to any questions on this form or willfully conceal any material fact, I will, if engaged, be liable to terminate my Contract of Service, either with or without notice.

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