the Alchemy Carta Job Application Form
The Alchemy Carta Limited
Hazel Drive
Leicester
LE3 2JE
TEL: 0116 2824824
FAX: 0116 2825202  		The Alchemy Carta Logo
ALL INFORMATION SUPPLIED HERE IS TREATED STRICTLY CONFIDENTIALLY AND FOR THE PURPOSES OF JOB APPLICATION ONLY
The Alchemy Group Website - Available Jobs
Position Applied For
Date:
 
Personal Details
Forename:
Surname:
Age:
Date of birth:
/ /
Sex:
Email address:
Town & County of Birth:
Nationality:
Land line number:
Mobile phone number:
Marital Status:
Number and age(s) of children:
Address
Address Line 1:
Address Line 2:
Town/City:
County:
Post Code:
 
Next of kin details
Relationship
    
Forename:
Surname:
Next of kin address, if the same as above, please tick box:
Address Line 1:
Address Line 2:
Town/City:
County:
Post Code:
 
 
Education (in ascending order, most recent first)
Further Education Dates Award(s) gained
Secondary Education Dates Examinations passed
Additional Languages: (after English)
Membership of professional Institutions, clubs or organisations:
 
Previous Employment (in ascending order, most recent first)
Please include unemployment for any period
Full dates of service Name and address of employer (or please state "UNEMPLOYED") Position Salary Reason for leaving
From
To
 
From
To
 
From
To
 
From
To
 
References
Application for a reference may be made to any previous employer. Please give below the names of TWO unrelated persons, to whom we may apply for character references.
Name Address  Connection
 
 
Computer Experience
Do you have a computer at home? Yes No
Do you have any computer Training Qualifications
 Yes No
If "Yes" please give brief details:    
Do you have any computer experience at work?  Yes No
If "Yes" please complete the following:
How much experience do you have? A little A reasonable amount A lot
 
In which fields?
General Office
Accounts
Art/Design/
DTP
Production
Internet
Media
Web-Design
Programming/
Development/
Tech-Support
 
On what platforms?
Windows
DOS
MAC
Cad/Cam
Other
Please list the applications in which you feel most proficient:
Please add any further computer experiences and qualifying notes below:
 
About You
What are your career ambitions?
What are your hobbies and interests? (Please give details of any talents or experience)
Do you have any personal ambitions? 
Do you hold a current driving licence? Yes No
Do you have your own transport? Yes No
Please give details of experience/skills you have which you feel are relevant to the position applied for,
and the reason you have applied for this position.
 
Medical Background
General Practicioner name:
Practice location:
Height:
Weight:
   
Are you affected by any of the following conditions?
 
Yes
No
  
Yes
No
Asthma
Stomach Trouble or Ulcer
Hay Fever
Back Strain
Any Other Allergy
Disc Trouble
Diabetes
Heart Disease
Jaundice
Fainting Spells
Skin Rash
Shortness of Breath
Dermatitis
High Blood Pressure
Eczema
Psychiatric Treatment/
Nervous Breakdown
Arthritis
Bronchitis
Rheumatism
Chronic Cough
Rupture
Rheumatic
Convulsions or Fits
Sinus Trouble
Tuberculosis
Kidney Trouble
Pneumonia
Varicose Veins
Chest Pain
Eye Trouble
Ear Trouble
Colour Blindness
Are you registered disabled? Yes No  
If "Yes", please give the following details:
Registered Disablement:
Registered Number:
Expiry Date:
/
I HEREBY CERTIFY THAT I HAVE ANSWERED ALL QUESTIONS TO THE BEST OF MY KNOWLEDGE AND THAT THE ANSWERS ARE COMPLETE AND TRUE. I GIVE PERMISSION FOR THE COMPANY MEDICAL OFFICER TO RECEIVE DETAILS OF ALL OR ANY OF THE ABOVE FROM THE RELEVANT DOCTOR, IF DESIRED
 
Where did you see this position advertised?:
 
I UNDERSTAND THAT IF I ACCEPT AN OFFER OF EMPLOYMENT AND ANY OF THE ABOVE INFORMATION IS SUBSEQUENTLY FOUND TO BE INCORRECT, MY POSITION OF EMPLOYMENT MAY BE INVALIDATED.
 
Thank you for completing the Alchemy Carta Job application form. If you are satisfied that all necessary information fields are correctly completed, please, submit the form by clicking the button below.