PERSONAL RECORD

AFFIX PHOTOGRAPH
PRIVATE AND CONFIDENTIAL IF POSSIBLE
Please complete in block capitals and black ink
GENERAL - Section 1
Title: Dr Mr Mrs Ms Other First Names:
Surname:
Present Address:
Postcode:
If less than 3 years, please state previous address:
Postcode:
Tel. No. (Home):
Tel. No. (Work):
Mobile No:
E-mail:
How did you hear of SSR?
Name of publication, exhibition, personal referral:
Position applied for:
Would you consider contract work? Yes No
Current basic salary:
OTE or bonus:
Minimum salary requirement:
What is your notice period?
Are you prepared to move
to another area? Yes No
If Yes, state preferred location(s):
Overseas:
National Insurance Number
Are you an EU Citizen?
Yes No
Country of Origin:
If no, do you have
unrestricted entitlement to take
up employment in the UK?
Yes No
Your work visa must be shown
ENVIRONMENT OFFICE USE ONLY BELOW
Job Titles
Market Sector
Product
INTERVIEWERS ASSESSMENT Interviewed by: Date:
Appearance: Special Aptitudes:
Personality: General Intelligence: Interests:
Attainments: Circumstances:
Have you seen and photocopied: Bank Statement Birth Certificate Passport Drivers Licence Utilities Account
10 Year Postal Audit
Year J FMAMJ J ASOND Year J FMAMJ J ASOND
5 Year Telephone Vetting
Year J F M A M J J A S O N D
HEALTH QUESTIONNAIRE - Section 2
1. Name and address of GP:
May we request medical information form him/her if necessary? Yes No
2. Have you had a Chest X-Ray in the last 2 years? Yes No
3. Have you ever attended an Outpatients Department for longer than 6 weeks? Yes No
If Yes, please give details:
4. (a) Please place a cross against any undermentioned illnesses from which you have suffered:
Asthma Epilepsy Heart Trouble Rheumatic Complaints
Back Trouble Fits Hernia Serious Skin Disorders
Bronchitis Fainting Migraine Tuberculosis
Diabetes Hay Fever Nervous Disorder
(b) Are you currently receiving any medical treatment? Yes No
(c) Do you suffer from colour blindness? Yes No
5. Please give details of any other serious illness, injury, operation, physical defect or disability:
6. How many days (approximately) have you been absent owing to illness in the last two years?
7. Are you registered under the Disabled Persons (Employment) Acts 1944 and 1958? Yes No
If Yes, please complete the following:
Certificate No. Expiry Date:
8. Have you been advised by a medically qualified person not to undertake night work? Yes No
UNEMPLOYMENT CONSENT FORM - Section 3
Each period of unemployment must be detailed on this form with name and full address of benefit office.
Applicants Full Name: National Insurance No.
Full address of Benefit Office:
Period of unemployment from: to:
Full address of Benefit Office:
Period of unemployment from: to:
Full address of Benefit Office:
Period of unemployment from: to:
Any further periods of unemployment should be completed and authorised on a separate sheet.
I (name of applicant) authorise SSR Personnel
to apply for details of the unemployment period(s) stated above.
Signed: Date:
PERSONAL REFERENCES - Section 4
Give the names and addresses of two personal referees known to you in excess of 10 years and in what capacity. These should not be relatives or
previous employers. School leavers/graduates should name their headmaster/tutor as applicable:
1.Name: 2. Name:
Address: Address:
Postcode: Profession: Postcode: Profession:
I certify that, to the best of my knowledge, the information that I have given is true and complete. I have never been convicted of any civil or criminal offence or
dismissed from employment for any misconduct. I understand that any false statement or omission may render me liable to dismissal without notice or prosecution.
I accept that I may be required to undergo a medical examination where requested by the Company and I consent to the results of such examination being given to
the Company. I understand and agree that if so required I will make a Statutory Declaration in accordance with the provisions of the Statutory Declarations Act 1835,
in confirmation of previous employment or unemployment. I authorise storage and retrieval of information supplied on this form and any attachments to assist in the
pursuance of my application for employment or for the Company to provide statistical analysis.
I have enclosed sheet(s) with my application
Applicants signature: Date:
Please complete in black ink
If accompanied by your CV
please record see CV
if information can be
cross referenced.
OFFICE USE ONLY
Applicant Ref. No. Location:
SSR Personnel Services
FREEPOST
London E17 6BR
Telephone: 020 8626 3100
Facsimile: 020 8626 3101
[email protected]
www.ssr-personnel.com
APPLICANT PROFILE - Section 5
Date of Birth: Age: Sex: Place of Birth:
Country of Marital Status: Former Name:
Origin:
Partners Partners Partners
Name: Occupation: Employer:
Children: Age(s): Accommodation: Owner occupier Rented Parents Home
Height: Weight: Smoker: Yes No
EDUCATION - Section 6
Name and address of Schools attended From To Exams Passed Grades
/ / / /
/ / / /
/ / / /
Name and address of Polytechnics, Highest Qualification
Colleges, Universities attended From To Type of Course Obtained
/ / / /
/ / / /
/ / / /
Membership of Professional Bodies, Training Achievements, etc.
Do you hold a current Driving Licence? Yes No Do you have your own transport?
Classification: Date of Issue: Yes No Company car: Yes No
Do you have any current or pending motoring offences? If so please state:
Do you speak any foreign languages? Yes No If yes, please state which and level of competence:
Spare time interests:
Have you ever received a police caution, been fined, sentenced to imprisonment or placed on probation for a criminal act (subject to the
Rehabilitation of Offenders Act): Yes No
Has any order been made against you by a civil or military court or public authority? No Yes Give details:
SELF ASSESSMENT - Section 7
Any comments you may wish to highlight as to your abilities or achievements:
EMPLOYMENT RECORD - Section 8
If this includes a period of self-employment, please give two referees i.e. bank/customer/supplier etc.
Name and full address of current or last Employer: Description of your duties/responsibilities:
Postcode:
Telephone: Fax:
Position held: Reporting to:
From: / / To: / /
Basic salary: OTE/bonus:
Description of Company:
Can we take up references? Yes No
Whom do we contact?
State reason for leaving/wishing to leave:
Section 9
Employment details Employment dates
Company Name: Position held: From: / /
Address: Reporting to: To: / /
Postcode: Basic salary: OTE/bonus:
Telephone: Fax: Reasons for leaving:
Company Name: Position held: From: / /
Address: Reporting to: To: / /
Postcode: Basic salary: OTE/bonus:
Telephone: Fax: Reasons for leaving:
Company Name: Position held: From: / /
Address: Reporting to: To: / /
Postcode: Basic salary: OTE/bonus:
Telephone: Fax: Reasons for leaving:
Company Name: Position held: From: / /
Address: Reporting to: To: / /
Postcode: Basic salary: OTE/bonus:
Telephone: Fax: Reasons for leaving:
Company Name: Position held: From: / /
Address: Reporting to: To: / /
Postcode: Basic salary: OTE/bonus:
Telephone: Fax: Reasons for leaving:
Company Name: Position held: From: / /
Address: Reporting to: To: / /
Postcode: Basic salary: OTE/bonus:
Telephone: Fax: Reasons for leaving: