APPLICATION FOR EMPLOYMENT -

- Step 1 of 16

POST

Job Title *

PROPOSED EMPLOYMENT TYPE *

PERSONAL DETAILS

Title *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile Telephone Number: *

Home Telephone Number:

Email *

Date of Birth *//

UK National Insurance Number

WORK PERMIT

Do you need a UK work permit to do this job under the terms of the Asylum and Immigration Act 1996? *

Where applicable please give details of any permit currently held: *

OTHER DETAILS

Do you have a valid driving licence for the UK *

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

EDUCATION & PROFESSIONAL QUALIFICATIONS

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

Number of qualifications you have *

First Qualification

Subject/Qualification *

Place of Study *

Grade/Result *

Year Obtained *

Second Qualification

Subject/Qualification *

Place of Study *

Grade/Result *

Year Obtained *

Third Qualification

Subject/Qualification *

Place of Study *

Grade/Result *

Year Obtained *

Fourth Qualification

Subject/Qualification *

Place of Study *

Grade/Result *

Year Obtained *

Fifth Qualification

Subject/Qualification *

Place of Study *

Grade/Result *

Year Obtained *

PREVIOUS EMPLOYMENT

Please provide details of the last five years. Fill in the current or most recent Employer Order.

Number of companies you have worked with (in past 5 years) *

First Employer Details (current or most recent)

Employer Name *

Employer Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone number *

Type of business *

Job Title *

Type Job Title *

Grade *

Salary *

Employment Dates *//

From

Employment Dates to *//

Reporting to *

Period of notice *

Reason for Leaving *

Description of your duties and responsibilities *

Second Employer Details

Employer Name *

Employer Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job Title *

Type Job Title *

Grade *

Salary *

Employment Dates *//

From

Employment Dates To *//

Reason for Leaving *

Third Employer Details

Employer Name *

Employer Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job Title *

Type Job Title *

Grade *

Salary *

Employment Dates *//

From

Employment Dates To *//

Reason for Leaving *

Fourth Employer Details

Employer Name *

Employer Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job Title *

Type Job Title *

Grade *

Salary *

Employment Dates *//

From

Employment Dates To *//

Reason for Leaving *

Fifth Employer Details

Employer Name *

Employer Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job Title *

Type Job Title *

Grade *

Salary *

Employment Dates *//

From

Employment Dates To *//

Reason for Leaving *

You have any year gap in last 5 years employment history *

Reason for year gap (in last 5 years employment history) *

TRAINING COURSES ATTENDED

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

Number of training course attended *

First Course

Course Title *

Training Provider *

Duration *

Date Completed *

Second Course

Course Title *

Training Provider *

Duration *

Date Completed *

Third Course

Course Title *

Training Provider *

Duration *

Date Completed *

Fourth Course

Course Title *

Training Provider *

Duration *

Date Completed *

Fifth Course

Course Title *

Training Provider *

Duration *

Date Completed *

Sixth Course

Course Title *

Training Provider *

Duration *

Date Completed *

Seventh Course

Course Title *

Training Provider *

Duration *

Date Completed *

Eighth Course

Course Title *

Training Provider *

Duration *

Date Completed *

Ninth Course

Course Title *

Training Provider *

Duration *

Date Completed *

Tenth Course

Course Title *

Training Provider *

Duration *

Date Completed *

MEMBERSHIP OF PROFESSIONAL BODIES

Include in this section any relevant professional registrations or memberships.

Registration For Membership *

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? *

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? *

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.

Number of References *

Referee 1

Name: *

Job Title: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone: *

Email *

Fax:

Relationship: *

Can the referee be approached prior to interview *

Referee 2

Name: *

Job Title: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone: *

Email *

Fax:

Relationship: *

Can the referee be approached prior to interview *

Referee 3

Name: *

Job Title: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone: *

Email *

Fax:

Relationship: *

Can the referee be approached prior to interview *

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 organisation. 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? *

If so, please give details *

DISABILITY

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

Do you consider yourself disabled? *

If disabled, do you need any special arrangements to enable you to undertake your role or attend interview? *

If so, please give details *

EQUAL OPPORTUNITIES MONITORING

Race Relations (Amendment) Act 2004. As an employer, Care Quality Commission (CQC) requires us 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:

I would describe my ethnic origin as follows:

I do not wish to disclose my ethnic origin

White

Black or Black British

Asian or Asian British

Mixed

Other Ethnic Group

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:

Gender *

I Prefer to Self Describe *

What does your sexual orientation lean towards *

I do not wish to disclose my religion/belief

I do not wish to disclose my religion/belief

Please indicate your religion or belief *

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:

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 organisation. This applies equally to any medical questionnaire/forms I may complete. By submitting this application form you consent to your personal details being used to process your emplyment application. Successful candidate’s data will be held under the company’s General Data Protection Policy, details of which will be made available upon the offer of employment. Full details are available in the staff handbook. Unsuccessful candidate’s data will be held for a period of 6 months where upon it will be confidentially destroyed. You can request that data that is no longer required to be held, can be removed from your file and destoyed.

I agree to the above declaration *

I agree to the above declaration

Name *

Date *

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