Personal details
Title:	Mr Mrs Miss Ms  Other:
Surname:
Forename(s):
Nationality:
Do you require a UK work permit?  Yes No

Home address:
Postcode:
Dates at this address:	until
Telephone (home):
Mobile number:
Preferred method of contact:  Home Mobile

Correspondence address (if different to above):
Postcode:
Dates at this address:	until
Telephone (home):

Email address:

Dates not available for interview:

Where did you hear about Blick Rothenberg? Careers Office Inside Careers ICAEW Our Website
	Recommendation by Partner / employee of Blick Rothenberg (please give details)
	Other (please give details)

Have you applied to Blick Rothenberg before?
If so, give details, including dates:

Secondary/Further Education
School(s) attended:

Please list all exams taken (GCSE, A Level, Highers or equivalent) including any fails or resits:

	Level	Subject	Grade

University Education
University/College/Institute:
Dates:	until
Title of Degree/Course:
Class:	Expected Obtained

Principal subjects:
1st Year:	Grade:
2nd Year:	Grade:
3rd Year:	Grade:
4th Year:	Grade:

Postgraduate Qualifications
University/College/Institute:
Dates:	until
Title of PhD/Diploma etc:
Name of supervisor:
Subject of course or thesis:

ALL ACADEMIC INFORMATION WILL BE VERIFIED, EITHER AT INTERVIEW, OR ON OFFER STAGE

 
Other Information

Please detail any scholarships, awards or prizes won, at school and University/College

Work Experience (please include vacation and part-time work)
Name of employer:
Dates:	until
Type of work:
Name of employer:
Dates:	until
Type of work:
Name of employer:
Dates:	until
Type of work:
Name of employer:
Dates:	until
Type of work:
Name of employer:
Dates:	until
Type of work:
Name of employer:
Dates:	until
Type of work:

Describe any other qualifications/skills, e.g., knowledge of foreign languages, IT programmes etc. (please indicate proficiency)

 
Activities and Interests
Give details of interests, achievements and responsibilities during your school/college/university career

 
Additional Information
Tell us a little more about yourself and why you’re interested in a career with Blick Rothenberg

When would you be free to start?

Have you ever been convicted of a criminal offence?   Yes  No
If ‘yes’, please give details of any conviction (other than offences regarded as ‘spent’ under the terms of the Rehabilitation of Offenders Act 1974)

Please detail any permanent illness or disability, outlining considerations to be taken into account during the recruitment process:

Please indicate your ethnic origin:
(this information is requested in accordance with the code of practice issued by the Commission for Racial Equality)

White British European White Other: Black or Black British Caribbean African Black Other Mixed:

Asian or Asian British Indian Pakistani Bangladeshi Chinese Asian (SE Asian) Other Asian (Indian Subcontinent) Other: Other ethnic group: Do not wish to specify

Referees 1st academic:
Name:
Occupation:
Address:
Telephone:

2nd employer/personal (no relatives):
Name:
Occupation:
Address:
Telephone:

Data Protection Act

I understand that my referees will be written to in the event that I am offered a position with Blick Rothenberg I give my consent to Blick Rothenberg to hold the above information on file. I understand that the processing of this information will comply with the Data Protection principles I declare that the above information provided in this application is correct and complete. I understand that any false or misleading information or statement may be sufficient grounds for terminating immediately either any arrangements made for interview or my employment

Date: (DD/MM/YYYY)