Solicited Application

Post Applied for (required)

Reference Number (required)

Title (required)

Last Name (required)

First Name (required)

Address (required)

Postcode

Telephone Number (required)

E-Mail (required)

Are you eligible to work in Zambia?

Yes No

Do you require a work permit to work in Zambia?

Yes No

Gender

Male Female

Phone(s)

Date of birth (mm/dd/yyyy)

Nationality

Ethnic group

ID Type

ID Number

Current/Last Employer

Address

Postcode

Employer's telephone number

Job Title

Salary

Leaving date or notice period

Reason for leaving

Previous employer

Address

Postcode

Employer's telephone number

Job Title

Salary

Leaving date or notice period

Reason for leaving

Field of study i.e. Education, administration

Date obtained

Name of institution

Referee 1

Post held

Address

Postcode

Email address

Telephone number

Your relationship to the referee

Referee 2

Post held

Address

Postcode

Email address

Telephone number

Your relationship to the referee

Referee 3

Post held

Address

Postcode

Email address

Telephone number

Your relationship to the referee

Name of professional body

Membership type/ grade

Date of affiliation

Name of professional body

Membership type/ grade

Date of affiliation

Name of professional body

Membership type/ grade

Date of affiliation

Other Information

Additional Information - Please use this space to tell us how you meet each of the points on the person specification. Please attach additional information if you require more space.

Are you related to, or have a close personal relationship with a member of staff at LICS?

Yes No

Name

Position held

Where did you see this post advertised?

Do you consider that you have a disability meaning long term illness, health problem or disability that limits your daily activities or the work you can do

Yes No

Have you ever been cautioned or convicted of a criminal offence?

Yes No

Have you ever been disqualified from working with children or vulnerable adults?

Yes No

Have you ever been cautioned or convicted of a criminal offence?

Yes No

I hereby declare that all the information provided in this application is true and accurate to the best of my knowledge. I understand that any false statements or omissions may result in disqualification from the application process.

Supporting documents (required)

Safer Recruitment Form

Current/Last Employer

Previous employer

Referee 1

Referee 2

Referee 3

Other Information