APPLICATION FORM
Applications must be completed in black ink or type

Post reference:
Post applied for:
  1. PERSONAL DETAILS

Surname / Family Name: / Title:
First Name (s):
Address:
Town / City: / Postcode:
Home Tel No: / Work Tel No:
Mobile No:
Email Address:
  1. CURRENT EMPLOYMENT / TRAINING POST DETAILS

Name of Employer:
Job Title:
Address:
Town / City: / Postcode:
Start Date:
Training Grade (if applicable):
NTN (if applicable)
GMC Number (if applicable)
  1. EDUCATION AND QUALIFICATIONS

Starting with the highest, please list academic and professional qualifications, together with grades:

Qualification and Grade / Name of Institution / Year of Graduation
  1. SKILLS, CONTINUING PROFESSIONAL DEVELOPMENT AND TRAINING

Please list any additional training or competences that you would like us to consider in support of your application:

  1. REFEREES

Please give the name and contact details of 2 people who have agreed to act as referees on your behalf, one of whom must be your present or most recent employer. The LETB treats all references confidentially:

Surname / Family Name: / Title:
Job Title:
Organisation:
Address:
Town / City: / Postcode:
Contact Number: / Email Address:
Please indicate whether a reference may be obtained prior to interview: / Yes / No
Relationship to you:

REFEREES (Continued):

Surname / Family Name: / Title:
Job Title:
Organisation:
Address:
Town / City: / Postcode:
Contact Number: / Email Address:
Please indicate whether a reference may be obtained prior to interview: / Yes / No
Relationship to you:
  1. MEDICAL, DENTAL AND OTHER CLINICAL STAFF ONLY

This section should only be completed by Medical, Dental and other Clinical staff only. Please give all details of professional registration eg GMC, UKCC as requested:

Name of Organisation: / Number:
Membership Status: / Expiry Date:
  1. RIGHT TO WORK IN THE UK

UK/EEA National
Indefinite Leave to Remain / Settled Status
HSMP
Tier 1 (No restrictions)
Tier 1 (No employment as a doctor in training or training restriction)
Tier 1 or 2 Dependant
Eligible for Tier 2
  1. SUPPORTING STATEMENT

In addition, candidates are asked to submit an additional statement of no more than one page of A4 outlining their suitability for the post and a copy of their current CV. CVs will not be accepted without a completed application form.

  1. DECLARATION

I confirm the information provided above, and in any attachments, is correct and understand that any false statement could result in my application or appointment being terminated.

I have completed all sections 1 to 8.

Signed: ______Date:______

EQUAL OPPORTUNITIES MONITORING FORM

Post Reference______

Surname______

First Name(s)______

Date of Birth______

GenderMALE/FEMALE

Disability YES/NO

NationalityUK/EEA/OTHER ______

Ethnic Group

White – British / Asian or Asian British Other Background
White – Scottish / Chinese
White – Irish / Mixed – White and Black African
White – Other Background / Mixed – White and Black Caribbean
Black or Black British – African / Mixed – White and Asian
Black or Black British – Caribbean / Other Mixed Background
Black or Black British – Other Background / Other Ethnic Background
Asian or Asian British – Indian / Not Known
Asian or Asian British – Pakistan / Information Refused
Asian or Asian British – Bangladeshi

DATA PROTECTION

The data you give will be processed in accordance with the Data Protection Act 1998.