Director of Human Resources
University of Birmingham
Edgbaston
Birmingham B15 2TT
Tel. 0121-415 9000
Fax. 0121-414 4802
www.hroperations.bham.ac.uk
	
Employment Application Form

Before you complete this application form, please ensure you click here and read the attached ‘information for applicants’ leaflet.

			
Post applied for		Advertised in			
			
Department/School			
			
Reference Number	Full / Part Time		
			
Surname or Family Name		Title (Mr, Ms, Dr, etc)			
			
Other Names			
			
Address			

			
					
		Post Code			
			
Tel (Home)		Tel (Business)			
			
Email		Fax			
					
National Insurance
Number			
	If you have previously applied for another post in the University, or if you are a former member of staff (whether paid or honorary), please quote your University person reference number		
			
	These data items are collected to ensure that the University is able to create and identify a unique record for you.		
	Would a work permit be required to employ you?   Yes		No		Please click here and refer to separate sheet for more information		
	Referees.	
	Referees may be consulted before interviews are arranged: please tick box if there are any that you would not wish to be consulted until a later stage		
	1.			2.			3.			

		

				
							
	tel.		tel.		tel.		
							
	fax		fax		fax		
							
	e-mail		e-mail		e-mail		
							
	capacity		capacity		capacity		

	  Education and Qualifications Obtained  Please  click here and refer to separate sheet for more information		

	

	  
Qualifications to be obtained  Please  click here and refer to separate sheet for more information		

	

			

	Present or most recent employment		
	Name and address of employer	Position(s)		
				
		Date from	Date to	Current Salary	
								
		Period of notice required by present employer			

	
Brief description of duties

	

	

Previous employment (in chronological order)	
	Name of Employer	Position	Dates		

		

	
Any other information Please click here and refer to separate sheet for more information		

		
	
	Dates I am not available for interview:			
	I confirm that the information provided on this form is correct and understand that any mis-representation or omission may render me liable to summary dismissal if engaged. I understand that the information will be stored in manual and electronic files and is subject to the provisions of the Data Protection Act. I agree to information provided on this form being used by the University in accordance with the Act, and, in particular, for equal opportunities monitoring. I understand that, if offered an appointment, I may be asked to complete a medical questionnaire and I agree to undergo a medical examination if required.		
					
	Signature		Date		

		

Please click here and refer to separate sheet for more information

Please state: 	
1	Your sex	Female		Male			
2	Your nationality or citizenship	
				
3	Your ethnic origin or racial group (put a mark in the box you choose)	
	White	British			
		Irish			
		Any other white			
	Mixed	White/Black Caribbean			
		White/Black African			
	White and Asian			
		Any other mixed background			
	Asian or Asian British	Indian			
		Bangladeshi			
		Pakistani		Error! Reference source not found.	
		Error! Reference source not found.Any other Asian background		Error! Reference source not found.	
	Black or British	Caribbean			
		African			
		Any other Black background			
	Chinese or other Ethnic group	Chinese			
		Any other Ethnic group			
4	Do you consider yourself to have a disability?Error! Reference source not found.	
	Yes		No			
5	Date of Birth