Application For Employment

Surname:

Other Names:

Title:

MR MRS MISS MS OTHER

Maiden Name:

Nationality:

Address:

Place of Birth:

Date of Birth :

Post Code:

Age:

Telephone Number:

Marital Status:

Work Number:

Number & Ages of Children:

1 2 3 4 5 none

Mobile Number:

Are you in good health?:

DfEE Number:

Are you a ?:

Smoker Non Smoker

NI Number:

Do you have transport for work?

Yes No

Do you have a current clean licence?

Yes No

Email address:
(Compulsory)

Bank Details:

I am Employed Unemployed at present. I am available for work between 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 11.00 12.00 am and 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 11.00 12.00 pm.

I require Permanent Supply employment as a

Do you have any criminal convictions other than those which are spent pursual to the Rehabilitation of Offenders Act 1974? Yes No

At this time is there any case pending against you or suspension from any previous employer for any offence? Yes No

What are your hobbies outside of work?

Have you ever worked temporarily for any other temporary agency? Yes No

If yes which one:

What type of work did you carry out? Rate per hour paid

Total number of years you have taught as a recognised qualified primary, secondary or special school teacher:

Please state which LEA you have previously worked for, please give dates etc:

Education & Qualification

Further/Higher Education (Including Proffessional Teacher Training)

Additional Qualifications, e.g. TESOL, CCRS (formerly Catholic Teacher's Certificate), sign language, etc.

Additional skills/abilities/areas of responsibility, e.g. music, arts, sports and outdoor pursuits, etc.

Key Stage Teaching Abilities

Age Group:

Nursery:

Speciality Experienced Can try Cannot do

Key Stage 1:

Speciality Experienced Can try Cannot do

Key Stage 2:

Speciality Experienced Can try Cannot do

Key Stage 3:

Speciality Experienced Can try Cannot do

Key Stage 4:

Speciality Experienced Can try Cannot do

A Level Grade:

Speciality Experienced Can try Cannot do

Employment History

Please list all teaching posts starting with the most recent appointment first (NQT's-pleae state teaching practice school)

Confidential Declaration of Health

Following the recomendations of the DfEE circular 13/93 we are required to satisfy ourselves that you have the physical and mental fitness to work with children in school or other educational estabishments. We, therefore, ask you to complete the medical history form below:-

1. Have you ever, to your knowledge, suffered from any of the following

a) Blackouts, epilepsy, fits or faints.

Yes No

b) Heart disease or disorder.

Yes No

c) High blood pressure.

Yes No

d) Tuberculosis, bronchitis, asthma.

Yes No

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