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Full-time Part-time Permanent Temporary Self Employed Ltd. Company
Male Female
Yes No
Yes No
Yes No
If Ltd Company/Self Employed:
Current or Most Recent Employer


Employer Name & Address Job Title/Grade/Salary Employment Dates Reason for Leaving
Include in this section all relevant qualifications. Please also include subjects currently being studied.
Subject/Qualification Place of Study Grade/Result Year
Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking.
Course Title Training Provider Duration Date Completed
Include in this section any relevant professional registrations or memberships__
Not required for this post I have UK registration I have applied for UK registration I have not yet applied for UK registration I have non-UK registration
If you are registered then please enter the relevant details below.
Professional Body Membership or Registration Type Member or Registration Or PIN Number Expiry or Renewal Date
If you are applying for a post that requires professional registration you are required to provide the following information:
Yes No
Yes No


Race Relations (Amendment) Act 2004
As an employer, we are required to collect details about an applicant’s ethnicity. This information is collected to fulfil that obligation and is used for monitoring purposes only.
I would describe my ethnic origin as follows:



Any other white background



Any other Black background




Any other Asian background

White & Black Caribbean

White & Black African

White & Asian

Any other mixed background


Any other ethnic group

In order to comply with these regulations employers are monitoring sexual orientation and religion/belief in applications.Please answer the following questions:

I do not wish to disclose my sexual orientation

Persons of the same sex

Persons of the opposite sex

Persons of the same and opposite sex

I do not wish to disclose my religion/belief










In order to protect certain vulnerable groups within society, there are a number of posts and professions that are exempt from the provisions of the Rehabilitation of Offenders Act 1974. These include posts where, in the normal course of their duties, successful applicants will have access to persons in receipt of health services. If the post you have applied for falls within the above category, it will be exempt for the provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act (Exceptions Order) 1975. Applicants are therefore not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by the employing organization. Any information given will be confidential and will be considered only in relation to posts to which the order applies.

No Yes

If you are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory disclosure from the CRB. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment.


Under the terms of the Disability Discrimination Act 1995 a disability is defined as a ‘physical or mental impairment which has substantial and long term effect on a person’s ability to carry out normal day to day activities’.



I do not wish to disclose




Please give the names of the people who have agreed to supply references. For all positions you must provide 2 references. If you are or have been employed these should be your two most recent employers, your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. If you are a student please provide contact details of a teacher at your school, college or university. Please note that personal references such as friends and relatives are not acceptable. For medical or financial posts you must additionally provide a 3rd reference. For all posts written references obtained must cover the preceding 3 years of employment. All referees will be approached prior to interview unless you indicate otherwise below.

Referee 1

No Yes

Referee 2

No Yes

In this section please give your reasons for applying for this post and additional information, which shows how you match the person specification for the job (you will have been sent this document with this application form). This can include relevant skills, knowledge, experience, voluntary activities and training etc. If relevant to the post for which you are applying you should include details about research experience, publications or poster presentation, clinical care (knowledge and skills) and clinical audit. Please continue on additional sheets if necessary.


The information in this form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organization. This applies equally to any medical questionnaire/forms I may complete.



This application form has been designed to provide the selection panel with sufficient basic information to carry out a preliminary assessment of your suitability for the post. All information given through the selection process will be treated in confidence by those involved in the appointment.


You do not need to disclose any criminal convictions which are considered “spent” under the Rehabilitation of Offenders Act 1974, unless the post you are applying for is exempt from the Act. If the position you are applying for is exempt from the Rehabilitation of Offenders Act, then you must declare in writing all criminal convictions, cautions, reprimands and warnings. This should be sealed in an envelope, and returned with your application form. This information will be processed in accordance with the Data Protection Act 1998, and will only be used to determine your character and suitability should you be successful for the position applied for. Should you be unsuccessful, this document will be destroyed unopened alongside your application form after a certain period.

Data Protection

Please note carefully that by signing the application form you are giving explicit consent for the data collected about you to be recorded and used for the following purposes. Data will be processed for administrative purposes connected with your application for employment. This information will be processed in accordance with the Data Protection Act 1998 and also the General Data Protection Regulations of (GDPR) 2018 conjunction with the Data Protection Act 2018.


We are unable to reply to individuals regarding their application unless they are short-listed. Anyone wishing to have an acknowledgement that their application has been received, should enclose a stamped addressed envelope with their application. If you have not heard from us within 4 weeks, unfortunately your application has not been successful.


In order to comply with the Asylum and Immigration Act 1996, any person attending and interview will be required to provide proof of the right to work in the United Kingdom. No offers of employment will be made to persons unable to provide identification. Equal Opportunities We actively promote equal opportunities and welcome applications from all sections of the community.


Please give names and address of two persons from whom references should be obtained. It is obviously in your own interests to seek approval before listing them as a referee. References should be taken from your most recent employer, and one other person who you know in connection with your work. Please state their position within the organization or relationship to you. We may take up references prior to interview. However, it is appreciated that taking up references at this stage can cause embarrassment. If you do not wish your references to be contacted at this stage please indicate as requested.

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