First Name Last Name Marital Status Married Widowed Separated Divorced Single Date of Birth Email Mobile Phone Full Address (Include City, Postcode) Nationality Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar, {Burma} Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe National Insurance Number Work Permit Type Expiry Date Possess a current Driving License? Yes No Do you possess own transport? Yes No Contact Name Relationship Telephone Number Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption Order 1957). Applicants are therefor, not entitled to withhold information about convictions which for other purposes are 'spent' under the dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an application for positions in which the Order applies, and should be entered at the end of any particulars you give in support of your application. A copy of our written policies are available upon request. A criminal record will not necessarily be a bar to obtaining a position. IHS Ltdcomplies fully with the Code of Practice, issued by the Department of Justice, in connection with the use of information provided to registered persons, their nominees and other recipients of information by Access NI under Part V of the Police Act 1997, for the purposes of assessing Applicants suitability for employment purposes, voluntary positions, licensing and other relevant purposes. We undertake to treat all applicants for positions fairly and do not discriminate unfairly or unlawfully against the subject of a disclosure on the basis of conviction or other information revealed. A full copy of the MPA's policy on the recruitment of ex-offenders is available on request.Have you ever been convicted of a criminal offence Yes No Do you have any spent or unspent criminal convictions? Yes No Have you supplied additional information with this application for any: Spent/Unspent convictions, cautions or reprimands? Yes No Have you ever been involved in Court Proceedings? Yes No Sex Male Female Marital Status Single Married Civil Partnership Divorced Widowed Other Community Background I'm a member of the Protestant Community I'm a member of the Catholic Community I am not a member of any Community Other (Comment in the below field) I am a member of another Community... (optional) Disability - Do you consider yourself as having a disability? Yes No Ethnic Origin English/Welsh/Scottish/Northern Irish/British Irish Gypsy or Irish Traveler Black African Black Caribbean Indian Pakistani Bangladeshi Chinese Arab, or Arab British Other (Please comment in below field) Ethnic Origin Additional Information (optional) The Regulations say that on average you should not be askedto work more than 48 hours in each week, taken over a 17 week period. By signing this Opt-Out Agreement, you will givev yourself the power to decide how many hours per week you want to work. It gives you the right to plan your working week however you may wish. You are under no obligation to sign this form. The Opt-Out Agreement is made under the provisions of the Working Time Directive (WTD) 1998 and such as forms part of your Contract of Employment with IHS Ltd. The WTD regulations ensure that the worker shall not work in excess of a 48 hour week, averaged over 17 weeks, unless they have agreed in advanced to do so. With effect from the 17th December 1999, workers who sign an individual 48 Hour Opt-Out Agreement, need not have their working hours recorded for monitoring purposes. Any worker that wishes to withdraw their Agreement to an existing 'Opt-Out' may do so after giving the appropriate notice to their employer. I hereby agree to 'Opt-Out' of the 48 hour agreement as specified in the "Working Time Directive". I understand that if I wish to revoke this in the uture then I am required to give Indiana Healthcare Services a minimum of 5 weeks' notice. Upload Documents Relevant to your application. (Required CV) Name of company #1 Name of referee #1 Telephone #1 Email Address #1 Name of company #2 Name of referee #2 Telephone #2 Email Address #2 Send