Application Form

Please complete the following application form.

Remploy is the UK's largest provider of employment opportunities for disabled people. The organisation supports over 5,500 people with a range of physical, mental and sensory disabilities or health conditions to find and retain work and gain financial independence with mainstream employers.

Remploy is an Equal Opportunities employer and they actively encourage candidate applications from all sections of the community.

If you need to receive this information in an alternative format, please contact CHH and we will arrange this for you.

General Details

Candidate Name
Position applied for
Telephone

CV Details

Regarding my CV, I would like to:

upload my CV fill out my details

Click the browse button to attach your CV:

In the event you do not have a CV please outline a brief overview of your
career history, skills, and experience:-

EQUAL OPPORTUNITIES MONITORING

Ethnic Category

The following categories are based on those used in the 2001 census as recommended by the CRE. Please note the ethnic questions are not about nationality, place or birth or citizenship. UK citizens can belong to any of the ethnic categories indicated.

Please tick one box below which best describes the ethnic category to which you belong:

White

British Irish Other

Any other White background - please write in below:

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Mixed

White and Black Carribean	White and Black African
White and Asian	Mixed other

Any other mixed background - please write in below:

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Asian or Asian British

Indian Pakistani Bangladeshi Asian other

Any other Asian background - please write in below:

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Black or Black British

Black Caribbean Black African Black other

Any other Black background - please write in below:

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Chinese

Chinese

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Traveller Community

If you are a member of the Traveller Community, please complete this section:

Gypsy/Romany Irish Traveller Traveller other

Please provide details below:

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Other

Other

Any other ethnic background - please write in below:

Gender

Please select the appropriate option:

Male Female

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If you identify as transgender, please tick appropriate box:

Male Female

Disability

Do you consider yourself to have a disability or a health condition?

Yes No Prefer Not to Say

Please place a tick next to the conditions which you have:

Hearing impairment and/or speech impairment
Visual/sight impairment
Learning difficulty (such as Down's Syndrome or Dyslexia) or                  cognitive impairment (such as Autistic Spectrum disorder)
Mental Health Condition, such as depression or schizophrenia
Physical Impairment, such as difficulty using your arms or mobility issues                   which mean using a wheelchair or crutches
Long-standing illness or health condition such as Cancer, HIV, Diabetes,                  Chronic Heart Disease
Neurological conditions, eg Epilepsy, MS
Any other specific disability needs or health condition you wish to declare

Please provide details below:

Multiple disability/health conditions declared?

Yes No Prefer Not to Say

Reasonable Adjustment

Do you wish to advise any future employer that you may require a reasonable adjustment to carry out your work?

Yes No Prefer Not to Say

If Yes, please state:

Communication Needs : Information in Alternate Formats

When we send any information or you attend an interview do you need any of the following?

In larger print (Example Arial size 16)
In Braille
In audio format (eg CD, audiotape
British Sign Language interpreter support needed
In any other format (please specify)

Please specify:

Age

Please state your age range:

16-17 18-24
25-34 35-44
45-49 50-54
55-59 60-64
65 or over

Prefer Not to Say

Religion

What is your Religion or Belief?

None
Buddhist
Christian - Catholic/Protestant
Hindu
Jewish
Muslim
Sikh
Any other religion or belief


Prefer Not to Say

Sexual Orientation

What is your sexual orientation

Heterosexual or straight
Gay
Lesbian
Bi-sexual
Other


Prefer Not to Say

Data Protection

I give my explicit consent for CHH to collect, process and share data with relevant third parties strictly on a need to know basis, in order to exceed legal compliance requirements and to improve services

Yes
No