Beechfield Medical Centre, Beechfield Gardens, Spalding PE11 1UN

POST APPLIED FOR: Dispensary Assistant (Maternity Cover)

  1. PERSONAL DETAILS

Title: / Forename and Surname:
Address & Postcode / Email:
Home Telephone No: / Daytime Contact No:
We are legally obliged to ensure that we only offer employment to those with a legal right to work in the United Kingdom:
Are you legally entitled to work in the United Kingdom? YES / NO
You will be required to provide evidence of your right to work in the United Kingdom. Should you be invited to interview, please bring with you originals of at least one of the following:
  • Your National Insurance number (your original N.I. Number, or on a P60 or P45)
  • A valid UK passport or Certificate of Naturalisation
  • A valid passport or identification card from a member country of the Economic area
  • A valid passport vetted by an immigration officer

2. YOUR CURRENT EMPLOYMENT

Start date and Leaving Date / Employer Name and Address / Job Title and Current Salary
or hourly rate of pay, and key achievements whilst in post. / Reason for Leaving, if already left

3. PREVIOUS WORK EXPERIENCE

Dates To and From / Employer Name and Address / Job Title Responsibilities and key achievements whilst in post / Reasons for Leaving

4. EDUCATION, TRAINING AND DEVELOPMENT

Secondary School, College, University, or Training
Establishment attended / Qualifications / course details / Date of Study

5. PERSONAL STATEMENT – Please continue on additional sheet if necessary

Please provide details of your experience including any unpaid work and outside interests that are relevant to the job that you have applied for and giveexamples. Tell us why you are the right candidate for this vacancy.

6. REFEREES – One must be your current or most recent employer – please note that we will not take up references until we have offered, and you have accepted, a position at the Practice

Name:
Address:
Email:
Telephone No:
Relationship to Applicant: / Name:
Address:
Email:
Telephone No:
Relationship to Applicant: recent employer

7. CRIMINAL CONVICTIONS

The Rehabilitation of Offenders Act 1974 requires applicants to give details of any convictions that are notspent. Failure to disclose such convictions could result in disciplinary action or dismissal if subsequently revealed after an offer of employment has been made and work has commenced.

The practice will also take up a Disclosure and Barring Service (DBS) check prior to you starting work, if the job is offered to you.

Do you have any previous convictions?

If yes, please detail offence(s) including date(s) and sentences(s)

8. HOLIDAY BOOKINGS and START DATE

Have you booked any holiday?YES/NO

If yes, please specify the dates:From:______To: ______

If you are offered a position at the practice please state when you could start work:

______

9. DECLARATION

I certify that the information contained on this application form is accurate and true. I give my consent to theprocessing, transfer and disclosure of all information submitted by me during the recruitment process andthroughout any subsequent periods of employment for pre-employment checks, equal opportunitiesmonitoring, payroll operations and training. (Data Protection Act 1988)

(IF THIS APPLICATION IS BEING EMAILED, IT MAY BE SIGNED AT INTERVIEW IF OFFERED ONE)

Signed:

Date:

10. SUBMISSION OF APPLICATION

Please submit your completed application form as follows:

Electronically (preferred): Save the application form to your own system, complete fully and forward to

By Post or by Hand to: Don McGeorge, Practice Manager, Beechfield Medical Centre, Beechfield Gardens, Spalding PE11 1UN marked “Strictly Confidential”.

Do not attach a CV.

PLEASE NOTE THAT THIS IS A TEMPORARY VACANCY TO COVER A PERIOD OF MATERNITY LEAVE ONLY

CONFIDENTIAL WHEN COMPLETED