PLEASE READ NOTES ON ATTACHED PAGE TO HELP YOU COMPLETE THIS FORM COMPLETED FORMS SHOULD BE RETURNED TO THE ABOVE ADDRESS OR EMAIL TO PERSONAL INFORMATION Title Mr / Mrs / Miss / Ms Names in Full Surname Contact Address Postcode Email address Contact Telephone Number(s) Home _______________________ Mobile ______________________ (if applicable) Personal Public Service Number (PPS) National Insurance Number Do you have (please tick √ box) A full current driving licence that allows you to drive in the UK, Isle of Man or Republic of Ireland? The use of a car for work? Yes  Yes  No  No  Do you require a work permit to work in the UK? Do you require a work permit to work in the Isle of Man? Do you require a work permit to work in the Republic of Ireland? Yes  Yes  Yes  No  No  No  Are you able to work flexible hours? This is particularly relevant to within our care projects Yes  No  Do you have a disability? (see Note 1) If yes, do you need any special arrangements to be made for you? Please tell us here what you need. Yes  Yes  No  No  Give dates of any planned holidays From To Praxis Care may not be able to accommodate holidays. Where did you hear about this job? Newspaper Internal  NI Jobs  Regional College Community NI  Praxis Care Website   Where you have ticked ‘Newspaper’, ‘Regional College’ or ‘Other’ - please specify_______________________ We use this information to measure the success of our adverts. REFEREES (see note 2) Name Address Name Address
We want to demonstrate that Praxis Care is a fair employer and that we are committed to equality of opportunity in employment. We are asking you to complete this section to enable us to monitor applicants for jobs. Monitoring helps us to ensure the organisation’s Equal Opportunities Policy is effective. Date of Birth Sex I am Male Female Other  (please tick √ box)  (Please specify ) ___________ Marital Status I am Single Married Divorced Widowed     Disability Do you have a disability? Have you any special requirements in order to access employment? Yes  Yes  No  No  Community Background I am a member of The Protestant community The Roman Catholic community Neither the Protestant nor the Roman Catholic community    RACE You must tick (√) one of the boxes below I am White Chinese Irish Traveller Indian Pakistani      Black African Black Caribbean Bangladesh Mixed Origin Other (please state)     ____________________ This section of the application form will be stored confidentially while information is being used for equal opportunities monitoring, and will then be destroyed. If your application for this job is successful, your information will be transferred to the Human Resources Management system, the use of which is strictly controlled. The identity of individuals does not appear in monitoring information. However, your individual information must be released to statutory bodies if requested. Please return the completed form with your Application Form. The information is treated as confidential and is only opened by the designated officers within the HR Department. The interview panel do not see it. NOTES ON HOW TO COMPLETE YOUR APPLICATION FORM – PLEASE TEAR OFF CV’s will not be considered Please read these notes carefully before completing your form.