Application form
Please use black inkJob applied for: Staff Nurse – Band 6
Job reference number: Ref: 17/42
Closing Date: 5pm on Friday, 20 October, 2017
Section one: Personal details
Mr Mrs Miss Ms Dr Other ………………….Surname: ______First Names: ______
Home address and postcode: ______
______
Telephone number (daytime): (evening):
______
Email address: ______
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Do you have any restrictions on working in the UK?Yes No
*If yes, do you hold appropriate work visa/permits for the full term of this job?
Yes No
*It is unlawful to employ a person aged 16 or over who does not have permission to live and work in the UK. You will need to provide us with one of the following documents:
A)Your passport, Birth Certificate or National ID card (for European Economic Area members only).
OR
B)A document providing your permanent National Insurance Number (e.g. P45, P60) plus one of the following; Birth Certificate (issued in the UK, Ireland, Isle of Man or Channel Islands) Certificate of Naturalisation as a British Citizen, letter from Home Office, granting indefinite leave to remain in the UK, Residence Permit.
OR
C)Your work permit plus one of the following: A passport or other travel document that shows leave to enter and take up work in UK, letter from Home Office proving right to enter and take up work.
We will not be able to employ you if you cannot produce one of these documents when requested.
Section two: Current Employment
Job Title: ______Salary:______(if successful you will be required to produce
Your employer: ______evidence of your salary)
Address and postcode: ______
______
______
______
The date you started: The notice you have to give:
______
The reason for leaving: The date you left(if applicable):
______
Please give brief details of your duties and responsibilities:
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Section three: Previous employment (most recent first)
Dates (mm/yy)From To / Your employer’s name and address / Your job title and main duties / Reason for leaving
Continue on additional
sheet if necessary
Are there any gaps in your employment history? Yes No
If yes, please explain these:
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Section four: Professional Qualifications and Training
Qualifications Awarding Body Date of CompletionMembership of Registered Body
Registration number: Expiry Date:
GMC
NMC (Part )
Other please state ______
Section five: Secondary & Further Education
Dates (mm/yy) School, college or Exams that youFrom To University passed
Section Six: Voluntary and Community Work
Please give details of any voluntary and community work you have been involved in.PTO
Section seven: Supporting statement
Please explain why you are applying for this job. Based on the person specification, provide specific examples to show how you meet each one of the essential and desirable criteria (if you need more space you may continue on a separate sheet but no more than two sides of A4).PTO
Section eight: References
We need to take references covering your last three years of employment. One referee must be your current employer. The nominated referees should be someone with line management responsibility who has supervised your work or a university or college tutor (if in further education within the last 3 years). We will not accept personal references.References will be taken up on shortlisting.
If you do not wish us to contact your present employer prior to interview, please in the space below.
Current Employer Previous Employer
Name: ______Name: ______
Position: ______Position: ______
Address and postcode: Address and postcode:
______
______
______
______
Telephone number: Telephone number:
______
PLEASE DO NOT TAKE UP THIS REFERENCE
AT THE PRESENT TIME:
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Section nine: Declarations:
Do you hold a current driving licence: YES/NO Enter Endorsements (if any), offence code and number of points issued?The post is exempt from the provision of Section 4(2) of the Rehabilitation of Offenders Act by an Exemptions Order, therefore, applicants are not entitled to withhold information about convictions which, for other purposes under the Act are ‘spent’. Failure to disclose any such convictions could result in dismissal or disciplinary action by the Hospice.
Have you ever been convicted of a criminal offence YES/NO
If YES, Please specify:
Date / Nature of Offence / Date ‘Spent’
Are you currently the subject of any investigation or proceedings by any body having regulatory functions in relation to health / social care professionals including such a regulatory body in another country?
YES/NO
Please give details on a separate sheet.
Have you ever been disqualified from the practice of a profession or required to practice it subject to specified limitations following a fitness to practise investigation by a regulatory body, in the UK or another country?
YES/NO
Please give details on a separate sheet
DISCLOSURE
If you are successful in your application for this post you will be asked to obtain a satisfactory disclosure from the Disclosure & Barring Service (DBS) prior to commencement in the post to check that you have no convictions that would render you unsuitable to work within a Hospice setting. The Hospice will also request checks and make referrals under the Protection of Vulnerable Adults Scheme (POVA).
DATA PROTECTION ACT 1998
Kirkwood Hospice will hold personal details of all applicants on computerised and manual records. Personal information will not be disclosed to a third party without your consent except where exemptions in the Data Protection Act exist. Anonymised personal data may also be processed by Kirkwood Hospice for research and statistical purposes.
Forms of unsuccessful candidates will be destroyed after six months.
DECLARATION
I declare that the particulars given are correct and l have not withheld any facts that may unfavourably affect my application. I accept that to withhold or falsify information could result in the termination of my contract. I agree to a medical examination if necessary. You can treat this as part of my contract of employment if I get the position.
Signed: Date:
PLEASE NOW CHECK THAT ALL SECTIONS OF THIS FORM HAVE BEEN COMPLETED
TO BE COMPLETED BY APPOINTING MANAGER
SHORTLISTING CRITERIA MET Yes/No / APPOINTMENT CRITERIA MET Yes/NoEquality & Diversity Data Collection Form
The Board of Trustees and Management Team of Kirkwood Hospice are committed to being open, honest and fair to all employees. We firmly believe that it is everyone’s right to be treated with dignity and fairness regardless of age, race, gender, religion or belief, sexual orientation, disability or marital status.
The data we collect will help us to monitor the diversity of our current workforce and to provide fair, open and honest treatment for our employees. The data will not be used for any other purpose.
Completing the questionnaire isn’t compulsory but by doing so you will be helping to make us a more accountable and transparent employer and to ensure we have sound information about the diversity of those who work for us to meet the requirements of the Equality Act now and in the future.
All data we have about employees is held securely and access is tightly controlled. In the case of your equality and diversity data, this will be held in a separate secure area of our database. Only those staff who are involved in maintaining the database and compiling statistics will have access to the data. The data will be used to generate statistical reports and undertake equality impact assessments.
Job Ref: 17/42
Surname: ______
First Name(s): ______
Date of Birth: ______
Where did you see the vacancy advertised: ______
Place an in the boxes using black ink.
Are you:MaleFemalePrefer Not To Answer
Please choose one box below which most closely matches your ethnic background.
WhiteBlack or Black BritishMixed Group
BritishCaribbeanWhite & Black Caribbean
IrishAfricanWhite & Black African
Any other Any other BlackWhite and Asian
White background backgroundAny other Mixed
background
(Please specify below if you wish) (Please specify below if you wish) (Please specify below if you wish)
Asian or Asian BritishChineseOther background
IndianChineseOther
PakistaniAny other Chinese
Bangladeshi background
Any other Asian
background
(Please specify below if you wish) (Please specify below if you wish) (Please specify below if you wish)
Prefer Not To Answer
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Disability
Are your day to day activities limited because of any health problem or disability which has lasted or is expected to last at least 12 months. Place an in one box only.
Yes-limited Yes-limited a little No Prefer not to answer
Disability is legally defined as a ‘physical or mental impairment which has a substantial and long term adverse effect on a person’s ability to carry out normal day-to-day activities’. This can include “hidden” conditions such as mental health conditions, epilepsy or diabetes for example.
Sexual Orientation
Bisexual Gay Woman/LesbianHeterosexual/Straight
Gay ManOther
Prefer not to answer
Which most closely matches your religion or beliefs?
BuddhistChristianHindu
JewishMuslimSikh
Prefer not to answerOtherI have no religious beliefs
(Please specify below if you wish)
Age Band:
Under 2525 to 3435 to 44
45 to 54over 54Prefer not to answer
Marital Status:
Married SingleDivorced
SeparatedCohabitingPrefer not to answer
If you have particular requirements in respect of any interview or selection test please give us details in the space below:
Name (in BLOCK CAPITALS): ______
The job that you have applied for: ______
Job Reference Number: ______
Details of particular requirements you might need:
If you have any questions or want to discuss your application in confidence, please contact Human Resources Administrator on tel: 01484 557900.
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KW SF11 APPFORM created 08/04/2008by HJT/CS/AM review Jan 09