Board Director of Healthwatch

Warwickshire CIC

Application Form

VACANCY APPLIED FOR: Board Director – Healthwatch Warwickshire CIC
Please complete in black ink or type
Surname:
First Name: / Home Address:
Post Code:
Telephone Numbers: / Home:
Mobile:
Work:
(May we contact you there – YES / NO)
E-Mail Address:
National Insurance Number:
Do you require a work Permit? YES / NO
(To comply with the Immigration, Asylum and Nationality Act 2006, you will be asked to provide original documentation of your eligibility to work in the UK.)
References:
Please give below the names and addresses of two referees who have known you for a minimum of six months, one of whom should be your present or most recent employer. References will be taken up for all shortlisted applicants, ideally, prior to interview.
Reference 1 / Name:
Position Held:
Address:
Post Code:
Contact Phone:
E-Mail Address:
Reference 2 / Name:
Position Held:
Address:
Post Code:
Contact Phone:
E-Mail Address:
Can we contact your referees before interview? / Reference 1:
Reference 2:
Supporting Statement:
Please provide one statement of recommendation to be attached to your completed application. This may be from one of your referees.
The statement of recommendation should include; in what capacity the person knows you (this can be personal or professional) and a statement from them of why they feel you would be the best person to take up the role of Chairperson for the Board of Healthwatch Warwickshire. / The person recommending me is:
Name:
Position Held:
Address:
Post Code:
Contact Phone:
E-Mail Address:
Declaration of Interests:
Do you have any business or personal interests that might be relevant to the work of Healthwatch Warwickshire which could lead to a real or perceived conflict of interest were you to be appointed? (Failure to disclose such information could result in an appointment being terminated.)
YES
NO
If Yes please give details:
Board Director – evidence of the expertise required
Details of the role and responsibilities are enclosed. Please give details of your experience, relevant skills and personal interest in relation to the criteria outlined and evidence of at least two of your key achievements.
Part of the selection process will be based on the information you provide in this application form.
Please continue on a separate sheet if necessary.
Please DO NOT send a CV.
To your knowledge, is there anything that may disbar you from taking up this role if offered?
If yes, please give details.
Declaration
I confirm that to the best of my knowledge and belief, the information given in this form is complete and correct. I understand that if I am appointed and the information I have provided is subsequently found to be untrue that my office may be terminated.
Signature: / Date:

Closing date -Monday 6th November 2017.

This form should be emailed to:

Or posted: HEALTHWATCH WARWICKSHIRE

4 & 6 Clemens Street

Leamington Spa

Warwickshire

CV31 2DL

Application form October 2017