Initial Application Form

Part 1 - Statement

I certify that, to the best of my knowledge, all the statements made below are true and accurate and, in particular, that I have not omitted any facts which may have a bearing on my application.
I give explicit consent that the information given on this form may be retained in conjunction with my personal file if I am successful. I understand it is Diagrama policy to destroy personal files 5 years after an employee’s leaving date. I further understand that vetting information will normally be destroyed 6 months after the end of employment of successful applicants and 6 months from the date of rejection of unsuccessful applicants.
Diagrama may take steps to verify the information that I have provided by contacting referees and checking professional registers.
I am aware that providing false information could result in my application being rejected or may lead to summary dismissal if I am selected for a position within Diagrama. If I am registered with any professional body Diagrama will inform them that I have provided false information on my application form.

Accept Terms

I confirm the above

Part 2 - Personal Details

Position applied for

Title

First Name

Last Name

Current Address

Postcode

Date From

Place of Birth

National Insurance Number

Telephone Contact No

Email Address *

Part 3 - Present or Most Recent Employer

Present or Most Recent Employer

Employer Address

Employer Postcode

Employer Telephone

Salary

Position Held

Hours

Full Time

Part Time

Date Started

Notice Period / Leaving Date

Key responsibilities of post and main achievements:

Reason for leaving:

PART 4 – Full Employment History & References

(include any self employment, voluntary work, periods of training/education and account for gaps in employment history – please provide explanations for any employment gaps.)

Diagrama reserves the right to contact any previous employer to verify information regarding your employment to ensure the safeguarding of the people in our care.

Employer Name 1

Employer Address 1

Employer Email 1

Start Date 1

End Date 1

Job Title & Main Duties 1

Reason for Leaving 1

Employer Name 2

Employer Address 2

Employer Email 2

Start Date 2

End Date 2

Job Title & Main Duties 2

Reason for Leaving 2

Employer Name 3

Employer Address 3

Employer Email 3

Start Date 3

End Date 3

Job Title & Main Duties 3

Reason for Leaving 3

Employer Name 4

Employer Address 4

Employer Email 4

Start Date 4

End Date 4

Job Title & Main Duties 4

Reason for Leaving 4

Employer Name 5

Employer Address 5

Employer Email 5

Start Date 5

End Date 5

Job Title & Main Duties 5

Reason for Leaving 5

PART 5 - Membership / Registration of Professional Bodies

Professional Body 1

Registration No. 1

Conditions Affecting Registration 1

Year Gained 1

Expiry Date 1

Professional Body 2

Registration No. 2

Conditions Affecting Registration 2

Year Gained 2

Expiry Date 2

PART 6 - Education

Qualifications / Level 1

Qualifications / Level 2

Qualifications / Level 3

Qualifications / Level 4

Qualifications / Level 5

Subject 1

Subject 2

Subject 3

Subject 4

Subject 5

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Year 1

Year 2

Year 3

Year 4

Year 5

PART 7 – Additional Information

Please provide a written statement detailing your knowledge, skills and attitude in support of your application and why you want to work in this role:

Additional Information

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