St. Columba’s Hospice

CONFIDENTIAL APPLICATION FORM

Position applied for:

Reference:

Please type in black text (or hand write in black ink)
1. PERSONAL
SURNAME / FIRST NAME(S)
TITLE (Dr/Mr/Ms etc)
PERMANENT ADDRESS
POSTCODE
WORK TELEPHONE / EMAIL
HOME TELEPHONE / BLEEP/PAGER
MOBILE TEL.
NATIONAL INSURANCE NO. / DO YOU HAVE A VALID/ FULL UK DRIVING LICENCE? / YES / NO
Are you a British subject or a national of any EU country? / YES / NO
If NO, do you have the right to work in the UK and a current work permit? / YES / NO
If so, please state the expiry date of your right to work in the UK and/or your work permit:
2. EDUCATION & PROFESSIONAL QUALIFICATIONS
PLACE OF STUDY / SUBJECT / QUALIFICATION / RESULT / GRADE / DATE OBTAINED
(mm/yyyy)
3. TRAINING COURSES ATTENDED
(any relevant training, or work related skills (for example languages, shorthand, etc)
TRAINING PROVIDER / COURSE TITLE/ SUBJECT / DURATION / DATE COMPLETED
(mm/yyyy)
4. PROFESSIONAL REGISTRATION
(e.g. GMC, NMC, HPC for posts where there is a requirement to be registered with a governing body)
GOVERNING BODY / REGISTRATION TYPE/ STATUS / REGISTRATION/
PIN NUMBER / EXPIRY/
RENEWAL DATE
Are you currently subject to any investigations or fitness to practise proceedings by a licensing or regulatory body in the UK or any other country? / YES / NO
If YES, please provide details with your application
Have you been removed from the register or have conditions been made on your
registration by a fitness to practise committee or the licensing or regulatory body
in the UK or in any other country? / YES / NO
If YES, please provide details with your application
5. MEMBERSHIP OF MEDICAL DEFENCE UNION/ PROFESSIONAL BODY OR ASSOCIATION
MEDICAL DEFENCE UNION / MEMBERSHIP GRADE / MEMBERSHIP NUMBER/ STATUS / DATE OF ENTRY
OTHER PROFEESIONAL BODY/ASSOCIATION / MEMBERSHIP GRADE / MEMBERSHIP NUMBER/ STATUS / DATE OF ENTRY
6. PRESENT OR MOST RECENT EMPLOYMENT
EMPLOYER NAME & ADDRESS
JOB TITLE / START DATE (mm/yyyy) / END DATE
(if applicable) / WEEKLY HOURS / SALARY/
GRADE / NOTICE PERIOD
BRIEF DESCRIPTION OF YOUR DUTIES AND RESPONSIBILITIES / REASON FOR LEAVING/ SEEKING CHANGE
7. PREVIOUS/OTHER EMPLOYMENT HISTORY
(Please start with most recent. Continue on separate sheet if necessary)
COMPANY/ ORGANISATION / POST HELD AND RESPONSIBILITIES/ DUTIES / DATE FROM / DATE
TO / REASON FOR LEAVING
8. SUPPORTING STATEMENT
Please provide your reasons for applying for this position and additional information that shows how you match the person specification. For example, details of your achievements, relevant skills, knowledge, experience, voluntary activities, positions of responsibility, as well as research, publications, clinical care, clinical audit (if applicable), awards and language skills. If you believe you have the necessary experience and skills – make sure you tell us!
Please continue on a separate sheet if necessary
9. REFERENCES
Please give the details of three referees who have consented to be approached and are qualified to comment on your ability and experience (references must cover at least the past 3 years, and one should be your current or most recent employer).
1st Referee 2nd Referee 3rd Referee
Name
Position
Organisation
Address
Postcode
Telephone
Email
May this reference be YES
taken up before interview? / NO / YES / NO / YES / NO
10. Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Order 2013
Because of the nature of the work which you are applying to undertake, you must disclose with your application for employment if you have any:
a.  ‘unspent’ convictions or cautions
b.  ‘spent’ convictions for offences on the ‘always disclose list’
If you have a ‘Spent’ conviction for an offence on the ‘always disclose’ list (https://www.mygov.scot/offences-always-disclosed), you must disclose it below. You are not required to disclose spent convictions for offences included in Schedule B1, ‘OFFENCES WHICH ARE TO BE DISCLOSED SUBJECT TO RULES’ until such time as they are included in a higher level disclosure issued by Disclosure Scotland. In the event of employment, any failure to disclose a criminal conviction as set out in ‘a’ and ‘b’ above could result in dismissal or disciplinary action by the Hospice. Any information given will be completely confidential and will be considered only in relation to an application for a position to which the Order applies.
Have you ever been convicted of a criminal offence, been bound over or cautioned or are currently the subject of proceedings which might lead to a conviction, an order binding you over or a caution, in the UK or any other country, which you must declare? / YES / NO
If YES, please provide details with your application
Protecting Vulnerable Groups (PVG) Scheme (Disclosure Scotland)
Are you an existing member of the PVG Scheme? / YES / NO
If YES, please state your full PVG membership number:
11. DECLARATION *Please read carefully before signing this declaration.
I understand that any appointment offered is subject to health clearance, confirmation of qualifications and professional registration, enhanced Disclosure Scotland (criminal records) check, and references, all of which must be deemed satisfactory by the Hospice. I hereby authorise you to carry out checks on all and any of my qualifications and/or registration from any establishment or employer and I give my consent to St. Columba’s Hospice processing the data supplied in this application form for the purpose of recruitment and selection.
I declare that the information I have given in support of my application is, to the best of my knowledge and belief, true and complete. I understand that if it is subsequently discovered that any statement is false or misleading, or that I have withheld relevant information, my application may be disqualified or if I have already been appointed, I may be dismissed without notice. This applies equally to any medical questionnaire/forms I may complete.
SIGNED / DATE
Please return your completed application form with any other attachments by the closing date:
By post: HR Office, By email:
St. Columba’s Hospice, TEL: 0131 551 1381
15 Boswall Road, FAX: 0131 551 2771
EDINBURGH, EH5 3RW
All information provided will be treated confidentially in accordance with the Data Protection Act 1998 and will be used for employment purposes. Information provided may be kept on an electronic or manual recording system.

Equal Opportunities Monitoring Form

We want to ensure that our job opportunities are open to all. The only way we can ensure there is equal opportunity is to monitor applications we receive. We would therefore be grateful if you would complete the questions on this form.

The form asks you for your ethnic origin, gender, disability, religion, sexuality and age. The information you provide in this part of the form is confidential and is not used in the selection process. It will be separated from the rest of your application when we receive it. Thank you for your assistance.

1. GENDER IDENTITY

How would you describe your gender?

Female

Male

Prefer not to answer this question

Do you consider yourself, or have you ever considered yourself transgender? This could include considering or intending to undergo gender reassignment surgery or not identifying with your assigned birth gender.

Yes

No

I prefer not to answer this question

2. AGE

What is your age?

Please specify age (in years)

I prefer not to answer this question

3. ETHNIC GROUP

What is your ethnic group?

For this question, please choose one section from A to E and then tick the appropriate box in that

section in order to indicate your ethnic group.

A. White

Scottish

Other British

Irish

Any other White background- Please specify

B. Mixed

Any mixed background

C. Asian, Asian Scottish or Asian British

Indian

Pakistani

Bangladeshi

Chinese

Other Asian background - Please specify

D. Black, Black Scottish or Black British

Caribbean

African

Other Black background - Please specify

E. Other ethnic background

Any other ethnic background - Please specify

I prefer not to answer this question

4. SEXUAL ORIENTATION

How would you describe your sexual orientation?

Heterosexual (straight)

Gay Man

Lesbian / gay woman

Bisexual Man

Bisexual Woman

Other - Please specify

I prefer not to answer this question

5. RELIGION AND BELIEF

Which of the following religions, religious denominations or bodies do you currently belong to? If you do not belong to any of these, please tick “None”.

None

Church of Scotland

Roman Catholic

Other Christian - Please specify

Buddhist

Hindu

Jewish

Muslim

Sikh

Other religion - Please specify

I prefer not to answer this question

6. DISABILITY
Do you have a physical or mental health condition or disability that has a substantial effect on your ability to carry out day to day activities, and has lasted or is expected to last 12 months or more?
(a)  Yes
(b)  No
(c)  I prefer not to answer this question

7. ADVERTISING

Where did you first hear about this vacancy?

e.g. “on s1jobs.com website”

Confidential Application Form for Employment Page 7 of 7