/ Recruitment
Application Form

Douglas Macmillan Hospice
Barlaston Road. Staffordshire. ST3 3NZ
t. 01782 344 300 f. 01782 300 344

Please Note: Any separate CV enclosed with this application will not be used during the selection process. Please do not send separate CVs, thank you.

Position applied for:

1.Personal Information (All information will be treated as confidential)

Title (Dr / Mr / Mrs / Ms / Miss) Other: / Home Address:
Postcode:
Forenames:
Surname (Block Capitals):
Tel. No. Home/Mobile: / Email address:
(Please note correspondence will be sent by email where possible)
Tel No. Work:
Do you require a work permit?
Do you hold a current UK Driving Licence?
Do you have regular use of a car? / Yes / No
Yes / No
Yes / No

2. Education and Training


General Education/Further Education E.G. GCSE’s, A-Levels, Degree. / Level / Please specify the name of the school, college or university you attended, including schools of nursing
Professional Qualifications/ Relevant Training Courses / Level / Year obtained / currently studying / Please specify the name of the college or university
Membership of Professional Body / Registration Number / Expiry Date
4. Current or Most Recent Employment, Volunteering or Work Experience
Name & Address of Organisation: / Post:
Date Of Appointment:
Salary/Wage:
(You May Be Required to Provide Evidence of This)
Period of Notice You Must Give:
Reason for leaving:
Please detail your role and responsibilities:

6. Previous Employment, Volunteering or Work Experience

Organisation Name
(most recent first) / Post Held and Brief Summary of Duties / Dates / Reason forLeaving
From / To

7. Statement of Suitability

This part of the application form gives you an opportunity to provide further information in support of your application. Please outline how you meet the person specification for this role. You may wish to continue on a separate sheet if necessary. A decision to shortlist is based on this information.

8. 8. References

Please give the names of two people who are able to provide references relating to your work experience and your suitability for the post. Your referees must be known to you in a professional capacity, one of which should be your current or most recent employer. Your referees should not be relatives or friends.

9. 9. Declaration

/ Recruitment
Monitoring Form

Douglas Macmillan Hospice
Barlaston Road. Staffordshire. ST3 3NZ
t. 01782 344 300 f. 01782 300 344

This information will be used solely for monitoring purposes and will be treated as Confidential.

(Please highlight your response).

Gender: / Male / Female / Prefer not to say
Age: / Under 16 / 16-21 / 22-30 / 31-40 / 41-50 / 51-60 / 60-65 / 65+ / Prefer not to say
Ethnicity: / Asian or Asian British - Bangladeshi / Indian / Pakistani / Any other Asian background
Black or Black British- African / Caribbean / Any other Black background
Mixed- White & Asian / White & Black African / White & Black Caribbean / Any other mixed background
White- British / Irish / Any other White background
Any other ethnic group -Chinese / other ethnic group
Prefer not to say
Religious Belief: / No religion or belief / Christian / Buddhist / Hindu / Jewish / Muslim / Sikh / Prefer not to say / Other
Sexual Orientation: / Heterosexual / Gay woman / Gay Man / Bisexual / Prefer not to say
Do you consider yourself to have a disability: / Yes / No
How did you hear of this vacancy:

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