Elderflower

First Name

Last Name

Address 1

Town/City

Postcode

Home Telephone

Work Telephone

E-Mail Address

Institution

From

Main Subjects

Qualifications

Specialised Training

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Employer

Position

From

£/anum

Starting Rate of Pay

£/anum

Leaving Rate of Pay

Reasons for leaving

Add

Current Notice Period

Do you have any holiday booked? Yes No

Holiday Dates

Reference 1

Telephone Number

Can we take up this reference before an offer is made? Yes No

Reference 2

Telephone Number

Can we take up this reference before an offer is made? Yes No

The Disability Discrimination Act 1995 (DDA) protects disabled people. The DDA defines a person as disabled if they have a physical or mental impairment, which has a substantial and long term (ie has lasted or is expected to last at least 12 months) and adverse effect on the person’s ability to carry out normal day-to-day activities.

The list below contains examples of the types of impairment:

Physical impairment, such as difficulty using your arms or mobility issues which means using a wheelchair or crutches.
Sensory impairment, such as being blind/having a serious visual impairment or being deaf/having a serious hearing impairment.
Mental health condition, such as depression or schizophrenia.
Learning disability such as dyslexia or cognitive impairment such as autism.
Long-standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy.
Other, such as disfigurement.

Do you consider yourself to be disabled? Yes No

do you require any particular facilities or adjustments to assist you:

A. To attend the interview? Yes No

Please provide details:

B. If you are offered employment? Yes No

Please provide details:

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Name

Address

Contact Information

Education

Other Qualifications

Work History

Supporting Statement

Notice Period

References

Reference 1

Reference 2

DISABILITY DISCRIMINATION

DISABILITY DISCRIMINATION

do you require any particular facilities or adjustments to assist you: