PECKHAMPLEX APPLICATION FORM

The following information will be treated in the strictest confidence.

Personal
(Please complete this section in BLOCK CAPITALS)

Surname: ___________________________________

First name: ___________________________________

Address: ___________________________________

___________________________________

Postcode: ___________________________________

Home telephone number: ___________________________________

Mobile telephone number: ___________________________________

Full Driving Licence: Yes / No Endorsements: Yes / No

_____________________________________________________________________________________________

Are you involved in any activity which might limit your availability to work or your working
hours e.g., local government? Yes / No
If YES, please give full details:
____________________________________________________________________________________________
_

Are you subject to any restrictions or covenants which might restrict your working activities?
Yes / No
If YES, please give full details:
____________________________________________________________________________________________
_

The company operates seven days per week. Please indicated the days you are available to
work:
MON TUE WED THU FRI SAT SUN

Have you any convictions (other than spent convictions under the Rehabilitation of Offenders
Act 1974?) Yes / No
If YES, please give full details:
_____________________________________________________________________________________________

If offered employment, you will be required to complete a Medical Questionnaire. Are you
prepared to undergo a medical examination before starting employment?
Yes / No

Have you ever worked for this Company before? Yes / No

_____________________________________________________________________________________________

Have you applied for employment with this business before? Yes / No

Do you have any friends or relatives who are currently working or have previously worked for
this company?
Yes/No
Do you need a work permit to take up employment in the U.K.? Yes / No

How much notice are you required to give to your current employer?

__________________________________________________________________________

Education

Schools attended since age 11 From To Examinations and Results

College or University From To Courses and Results

Further Formal Training From To Diploma/Qualification

Job related Training Courses Date Subject

Please give details of membership of any technical or professional associations:

______________________________________________________________
Please list languages spoken and the level of competence:
______________________________________________________________

______________________________________________________________
Employment Details

Please give details of your past employment, excluding your present or last employer, stating
the most recent first.

Name and address Dates Position held/Main duties Reason for

Present or Last Employer

Are you currently employed? Yes / No

Name of present or last employer: ___________________________________

Address: ___________________________________

___________________________________

Telephone number: ___________________________________

Nature of business: ___________________________________

Job title & brief description of duties: ___________________________________

___________________________________

Reason for leaving: ___________________________________

Length of service: From: ____________ To: _____________

______________________________________________________________

______________________________________________________________

Supplementary Information
Please set out below any further information to support your application
(e.g. past achievements, future aspirations, personal strengths)

______________________________________________________________

______________________________________________________________

Declaration
I declare that the information given in this form is complete and accurate. I understand that
any false information or deliberate omissions will disqualify me from employment or may
render me liable to summary dismissal. I understand these details will be held in confidence
by the Company, for the purposes of ongoing personnel administration and payroll
administration in compliance with the Data Protection Act 1998. I undertake to notify the
Company immediately of any changes to the above details.

Signed: _____________________________________________________________

PRINTED: _____________________________________________________________

Date: _____________________________________________________________

References
Please give the names of two people (one of which should be your present or most recent
employer) whom we may approach for a reference.

Can we approach your current employer before an offer of employment is made? Yes / No

Name: Name:
Position: Position:
Address: Address:

Tel. No: Tel. No:

Source of Application
How did you hear of this vacancy? __________________________________________