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POST

Post applied for:

Preferred employment type:

Full-time Part-time Permanent Temporary Self Employed Ltd. Company

PERSONAL DETAILS

Title :

Family Name:

Forenames :

E-mail :

Date Of Birth :

Gender:

Male Female

UK National Insurance Number:

Do you have a valid driving license for the UK:

Yes No

If yes, do you have access to a vehicle which can be used for work purposes:

Yes No

CONTACT DETAILS

Address :

Town/City :

Postcode :

Home Telephone Number :

Mobile Telephone Number :

Work Telephone Number:

May we contact you at work:

Yes No

If Ltd Company/Self Employed:

Company Name:

Address:

UTR Number:

EMPLOYMENT HISTORY

Current or Most Recent Employer

Employer name :

Employer address:

Telephone number:

Type Of Business:

Job Title:

Grade:

Start Date :

End Date:

Salary:

Reporting to:

Notice period:

Reason for leaving:

Description of your duties and responsibilities:

Employer Name & Address	Job Title/Grade/Salary	Employment Dates	Reason for Leaving

IMMIGRATION STATUS

Nationality:

Immigration Status:

EDUCATION & PROFESSIONAL QUALIFICATIONS

Include in this section all relevant qualiﬁcations. Please also include subjects currently being studied.

Subject/Qualiﬁcation	Place of Study	Grade/Result	Year

TRAINING COURSES ATTENDED

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

MEMBERSHIP OF PROFESSIONAL BODIES

Include in this section any relevant professional registrations or memberships__

My Professional Registration Status is:

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:

Are you currently the subject of a ﬁtness to practice investigation or proceeding by a licensing regulatory body in the UK or in any other country?

Yes No

Have you been removed from the register or have conditions been made on your registration by a ﬁtness to practice committee or the licensing or regulatory body in the UK or in any other country?

Yes No

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EMPLOYMENT EQUALITY REGULATIONS 2003

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

What does your sexual orientation lean towards?

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

Please indicate your religion or belief:

I do not wish to disclose my religion/belief

Atheism

Hinduism

Sikhism

Buddhism

Islam

Other

Christianity

Jainism

REHABILITATION OF OFFENDERS ACT

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.

Have you at any time received, or had pending, a court conviction?

No Yes

If so, please give details:

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.

DISABILITY

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’.

Do you consider yourself disabled?

Yes

I do not wish to disclose

If disabled, do you need any special arrangements to enable you to attend?

Yes

If so, please give details:

REFERENCES

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

Name

Job Title

Address

Telephone

Fax

Relationship

Can the referee be approached prior to interview?

No Yes

Referee 2

Name

Job title

Address

Telephone

Fax

Relationship

Can the referee be approached prior to interview?

No Yes

SUPPORTING INFORMATION

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.

Supporting Information:

DECLARATION

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.

I agree to the above declaration Yes

Name:

Signature:

Date:

GUIDANCE NOTES

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.

Disclosure

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.

Acknowledgement

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.

Interviews

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.

References

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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BASIC DETAILS

If Ltd Company/Self Employed:

EMPLOYMENT HISTORY

Current or Most Recent Employer

EMPLOYMENT DETAILS

IMMIGRATION STATUS

EDUCATION & PROFESSIONAL QUALIFICATIONS

Include in this section all relevant qualiﬁcations. Please also include subjects currently being studied.

TRAINING COURSES ATTENDED

Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking.

MEMBERSHIP OF PROFESSIONAL BODIES

Include in this section any relevant professional registrations or memberships__

If you are registered then please enter the relevant details below.

If you are applying for a post that requires professional registration you are required to provide the following information:

DECLARATION

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:

EMPLOYMENT EQUALITY REGULATIONS 2003

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

REHABILITATION OF OFFENDERS ACT

DISABILITY

REFERENCES

Referee 1

Referee 2

SUPPORTING INFORMATION

DECLARATION

GUIDANCE NOTES

Disclosure

Data Protection

Acknowledgement

Interviews

References

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