Date: 19 May 2012
Position(s) Applied for :
 
  PERSONAL DATA
FIRST NAME:
 		 LAST NAME: MIDDLE NAME:
ADDRESS:  
 		 COUNTRY:
Telephone No.    (Home)     (Other)     (c/o)
 
Sex:      Male        Female WEIGHT:    HEIGHT:
MARITAL STATUS:      
  		Single

Married
 

 Widowed

Divorced
 
N.I.S: NATIONAL REGISTRATION NO.:   
DATE OF BIRTH: COUNTRY OF BIRTH:    NATIONALITY:

NAME OF NEXT OF KIN:     RELATIONSHIP:
ADDRESS: TEL. NO.
OCCUPATION:    COMPANY:    TEL. NO.
  
  EMPLOYMENT INFORMATION

1. Have you ever been employed by a processing plant?    Yes    No
If yes, please indicate when
In what capacity

2. Do you have any impairments or disabilities (physical, mental or medical)?   Yes    No
If yes, describe in detail:

4. Have you ever been convicted for violation of the law?    Yes    No
If yes, please explain the circumstances of your conviction, indicating the date, name and place of the offence.

5. The following conditions may be required at some point in a job assignment. If required, would you be willing to work:

a)  Shift Work? Yes    No b)   Bank Holidays? Yes    No
c)  Work schedule other than Monday thru Friday? Yes    No d) Overtime? Yes    No

 
  EDUCATION AND TRAINING

EDUCATION (List most recent first)
 
Schools, Institutions, Technical College or University DATE QUALIFICATIONS (Certificates, Diplomas or Degrees)
FROM TO

Have you any other skills or abilities which might interest us? (e.g Foreign Languages, Computer Aptitude, Mechanical Aptitude, Apprenticeships, etc.)

 
FOREIGN LANGUAGES 1. READ   WRITE   SPEAK
(List fluent only) 2. READ   WRITE   SPEAK

 

  EMPLOYMENT EXPERIENCE

Please list your job history for the past ten years (or last three employers). Start with your present or last employer.
 
Company Name and Address Dates Employed
month/year		 Rate of Pay Position Held Reasons for Leaving
From $
To per Supervisor
Tel. No.
From $
To per Supervisor
Tel. No.
From $
To per Supervisor
Tel. No.

 
  REFERENCE

Please list three references. (The names of relatives must not be given)
NAME OCCUPATION COMPANY NAME TELEPHONE
1.
2.
3.

Are you related to, or do you know, anyone employed within our organization?  Yes      No
If yes please indicate below.
NAME POSITION DEPARTMENT RELATIONSHIP OF THIS PERSON TO ME

 

When would you be able to join this company?

I declare that all information given is true, complete and correct; and I understand it is subject to verification by Chickmont Foods Ltd. I understand that an offer of employment is contingent upon submission of a clean record on a Police Certificate of Character and medical proof of stability for employment. If subsequent to employment any information on this form is found to be incorrect or false, I agree that the company may terminate my employment.

I Accept           I Do Not  Accept