Dudley
General Information
Please ensure you fill in all fields where possible, if a field doesn't apply please just use "N/A".
Title Mr Miss Ms Mrs
Full Name
Date of Birth
Email Address
Telephone
Which position are you registering for? --- Head Chef Kitchen Assistant
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Current Address
Address Line 1
Address Line 2
City
County
Postcode
Date (month & year) moved in (01/2020)
Address History if applicable
If you've had a different address or addresses from your current in the last 5 years, please also include dates (month & year) moved in and out.
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Personal Details
National Insurance Number
Place of Birth
Change of Name (if applicable)
Date of Name Change
Previous Name
Do you drive? Yes No
DBS Certificate Number
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Professional Reference 1
Your current or most recent employer
Contact Name
Contact Number
Contact Email
Professional Reference 2
Someone in a professional capacity i.e. nurse, doctor, manager etc
Contact Name
Contact Number
Contact Email
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Payment Details
This is an optional step. If you would prefer to give us this information over the phone or via email, please do not forget to do so.
Sort code (6 digit number e.g 12-34-56)
Account Number (8 digit number e.g 12345678)
Account Name
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ID Confirmation
Please upload here three of the following Drivers Licence, Passport, Utility Bill or Birth Certificate (We need at least 3 of the 4 options)
ID 1:
ID 2:
ID 3:
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Health Questionnaire
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Marital Status:
Select N/A for not applicable.
Single Partnered Married Separated Divorced Widowed N/A
Childhood Illnesses:
Select N/A for not applicable.
Measles Mumps Rubella Chickenpox Rheumatic Fever Polio N/A
Immunisations:
Select N/A for not applicable.
Tetanus Pneumonia Hepatitis Chickenpox Influenza MMR COVID-19 N/A
List any medical problems that have been diagnosed that may affect your ability to work:
List any long-term medications that you are prescribed that may affect your ability to work:
Next of Kin Details
Name
Address
Contact Name
Relationship to you
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Criminal Convictions
Have you ever been convicted by the courts or cautioned, reprimanded, or given a final warning by the police? Please give details of offences, penalties and dates in the table below. Yes No
If you answered yes, please specify details including dates below
Have you ever been disqualified from work with vulnerable adults or sanctions imposed by any regulatory body?
Yes No
If you answered yes, please specify details including dates below
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Employee Statement
Choose the statement below that applies to you, either A, B or C.
Statement A
Do not choose this statement if you're in receipt of a State, Works or Private Pension.
This is my first job since 6 April and Since the 6 April I've not received payments from any of the following:
Jobseeker's Allowance
Employment and Support Allowance
Incapacity Benefit
Statement B
Do not choose this statement if you're in receipt of a State, Works or Private Pension.
Since 6 April I have had another job but I do not have a P45. And/or since the 6 April I have received payments from any of the following:
Jobseeker's Allowance
Employment and Support Allowance
Incapacity Benefit
Statement C
Choose this statement if:
You have another job and/or
You're in receipt of a State, Works or Private Pension
Which of the statements above applies to you?
Statement A Statement B Statement C
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Student Loans
Tell us if any of the following statements apply to you:
you do not have any Student or Postgraduate Loans.
you're still studying full-time on a course that your Student Loan relates to.
you completed or left your full-time course after the start of the current tax year, which started on 6 April.
you're already making regular direct debit repayments from your bank, as agreed with the Student Loans Company.
Do any of these statements apply?
Yes No
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Student Loans Continued
To avoid repaying more than you need to, choose the correct Student Loans that you have. Use the guidance below to help you.
Plan 1
you lived in Northern Ireland when you started your course
you lived in England or Wales and started your course before 1 September 2012
Plan 2
you lived in England or Wales and started your course on or after 1 September 2012
Plan 3
you lived in Scotland and applied through the Student Award Agency Scotland (SAAS) when you started your course.
Plan 4
you lived in England and Started your Postgraduate Master's course on or after 1 August 2016
you lived in Wales and started your Postgraduate Master's course on or after 1 August 2017
you lived in England or Wales and started your Postgraduate Doctoral course on or after 1 August 2018
Choose all that apply:
Plan 1 Plan 2 Plan 4 Postgraduate Loan (England and Wales Only) No Plan
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COVID-19 Vaccination Record
Please upload here your COVID-19 vaccination card as proof you're vaccinated against COVID-19.
Upload Here:
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Step 13GDPR Acceptances
As part of the GDPR new law which came into effect in May 2018, Advantage Angels are conscious that all personal information given is processed in a fairly and lawful manner. Information is processed only for specified and lawful purposes.
Please be advised that some information may be shared with only integral third parties. Personal data will be kept securely and not kept longer than necessary. Consequently, data will be destroyed suitably.
Any questions, please contact our HR department, info@advantageangels.co.uk.
I accept
Legal Acceptances
I confirm that the information I have given on this form is correct and complete and I understand that any false information could result in my application being rejected or, if appointed, in my dismissal from employment. I understand that any offer of employment made to me will be subject to a further check with the Disclosure and Barring Service (previously Criminal Records Bureau) and I hereby give my consent for Coram to carry out the relevant DBS status checks in line with the DBS Code of Practice.
I declare that I am not currently on the DBS Barred List and that I will notify the Human Resources department immediately if I do become barred in future.
I confirm
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