The Hillingdon Hospitals NHS Foundation Trust

Non-Executive Director Application Form

Please read the guidance notes which should help you complete this application form.

Part 1: Your personal details

Surname
Forenames
Title
Home address
Postcode
Contacts / Phone / Mobile
Email
Which address would you prefer for correspondence? (add an X where relevant)
Home / Business
Your current Job Title and Organisation (if applicable)

Part 2: How you found out about this post

(add an X where relevant)

Local Newspaper / Which one
National Newspaper / Which one
Website / Which one
Word of mouth
Other / Please give details

Part 3: Previous NHS or other Dept. of Health posts held

Have you held any other chair or non executive positions in the past 3 years?
No / Yes

If yes, please give details:

Board / Post / Dates

Part 4: Declaration of interests

Do you have any personal or business interests that may be relevant to the work of The Hillingdon Hospitals NHS Foundation Trust and which could lead to a real or perceived conflict of interest should you be appointed? If so please state. (Failure to disclose this information could lead to your appointment being terminated).
No / Yes

If yes, please give details:

Time commitments: Appointees' other significant commitments should be disclosed to the Council of Governors prior to the Governors confirming the appointment. This is to provide assurance to the Council of Governors that the proposed appointee has sufficient time to devote the 2.5 days a month to the position of Non-Executive Director at the Trust. Please state your other significant time commitments, including an indication of the time commitment for each role.

Ensuring public confidence: Should you be successful in your application, is there anything in your personal or professional history if brought into the public domain may cause embarrassment or disrepute to the Trust? If so please state. (Failure to disclose this information could lead to your appointment being terminated).

Please give details (if applicable):

Part 5: Future contact

If you are unsuccessful in this application, may we keep your contact details to inform you of future Non-Executive Director vacancies?
No / Yes

Part 6: References

Name / Name
Address / Address
Postcode / Postcode
Tel. No. / Tel. No.
E-mail / E-mail
How do you know him/her? / How do you know him/her?
May we contact them before interview?
No / Yes

Part 7: Evidence that you have the expertise required to be a Non-Executive Director

Please give specific evidence of your expertise and experience to show how this meets the requirements. All candidates must complete the first section. In section 2 please complete relevant information and leave others blank. Candidates should restrict their responses to no more than 150 words on each section. Where relevant please give brief information about the organisation so we can judge its size and complexity. Please give details of your experience and key achievements.

Please attach a CV (2 sides of A4 max) to supplement your application.

Section 1: Please complete this section
Essential expertise: Significant and senior level expertise gained in a comparably sized and complex organisation in the public, private or voluntary sector.
Section 2: Candidates are asked to demonstrate their experience against all of the essential criteria, and against as many of the desirable for which you can offer expertise. Please include brief information about the organisation so that we can judge its scale and complexity, and keep your responses to 150 words max for each individual criteria.
Essential expertise:
a) Adaptability and commitment to the changing NHS environment.
b) Ability to both challenge and work collaboratively.
c) Experience of negotiating with and influencing key stakeholders.
Desirable Expertise:
a) Recent experience as a medical consultant or recently practising GP with an interest in and experience of the new commissioning arrangements, or
b) Expertise in marketing and managing customer relationships, or
c) An understanding and/or experience in service provision for disadvantaged groups.

Part 8: Declaration

I confirm that to the best of my knowledge and belief, the information given in this form is complete and correct.

I further confirm that I have considered and understood the criteria for disqualification from appointment (which are set out in the candidate information pack) and that I am eligible for appointment, including living within the Public Constituency of the Foundation Trust.

I understand that if I am appointed and the information I have provided is subsequently found to be untrue then my tenure of office may be terminated.

Name
Date

1