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Application Form

Post Applied for: / Just ‘B’ Fundraiser
Full time / Part time / Bank / Full Time
Mr/Mrs/Miss/Ms/
Other
/ Forenames:

Surname

/ /

Previous names:

/
Contact Details: (Please tick preferred contact detail)
Address:
Post code / Home telephone:
Work telephone:
Mobile telephone:
Email address:

Employment History

Present or most Recent Post

Current Employer

/
Job Title
Date Employed from/to
Current Salary
Duties / Key Achievements
/ Reason for leaving

Previous Employment

(Please give details of all jobs held including part time and unpaid work, please continue on a separate sheet if required)

Employer /
Jobs Held / Key Achievements
/ Reason for Leaving

Education and Professional Qualifications

General Education

School / Qualifications / Results
Professional Qualifications, degrees, diplomas
College / Course / Qualification
Personal Development
Personal Development (include any courses, membership, voluntary work or responsibilities you consider relevant, with outcomes where applicable.

Supporting statement

Please include information to identify how you fulfil the person specification for the post . Please continue on a separate sheet if necessary.

Referees

Please supply the name, email address, and telephone number of 2 Referees (one of the references must be your present or most recent employer). They will not be contacted unless a job offer is made to you. A postal address should be supplied only if no email address is available.
Name: / Name:
Email: / Email:
Telephone: / Telephone:
Address: / Address:
Declaration
I confirm that I give consent for the information provided on this form to be used for recruitment and employment purposes in accordance with the Data Protection Act 1998.
I understand that anything I hear or learn concerning individual patients or my work at Saint Michael's Hospice in the course of my duty must be treated in the strictest of confidence in accordance with the policy. I note that breach of confidence is a disciplinary matter and may lead to dismissal
I declare that the information I have given in this application is accurate and true. I understand that providing misleading of false information will disqualify me from appointment or, if appointed, may result in my dismissal.
Signed Date
How did you become aware of this vacancy? (If on the internet, please state where)
Please return this form to:
Helen Flemming
Saint Michael's Hospice,
Hornbeam Park Avenue,
Harrogate,
HG2 8QL
Declaration of Criminal Record
Name:
Post applied for:
Saint Michael’s Hospice has a duty of care to protect the vulnerable adults and children who receive support.
As stated in the Hospice Equal Opportunities Statement applicants will not be discriminated against due to declared convictions and cautions, but will be considered on their merit. Should a successful candidate have any convictions or cautions the nature of the position and the circumstances and background of the offences will determine if it is possible to proceed with the appointment.
As Saint Michael's Hospice meets the requirements in respect of exempted questions under the Rehabilitations of Offenders Act 1974 all applicants aged 18 or over who are offered employment (paid or unpaid) will be subject to a criminal record check from the Disclosure and Barring Service (DBS) before the appointment is confirmed. This will include details of cautions, reprimands or final warnings, as well as convictions.
Saint Michael’s Hospice abides by the strict DBS Code of Practice with regard to disclosure whereby any convictions disclosed will not necessarily be a bar to employment.
Are you registered with the DBS Update Service? (Please tick the appropriate box)
Yes / No
If you have answered Yes to the above question, do you give permission for Saint Michael’s to carry out a Status check? (Please tick the appropriate box)
Yes / No
Have you ever been convicted by the courts or cautioned, reprimanded or given a final warning by the police? (Note that the post you have applied for is excepted from the Rehabilitation of Offenders Act 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need to be disclosed – even if you consider these to be ‘Spent’). (Please tick the appropriate box)
Yes / No
If yes, please give details of offences, penalties and dates:
Are you aware of any police enquires undertaken following allegations made against you, which may have a bearing on your suitability for this post?
Yes / No
If yes, please give details:
If you have declared a criminal record and we believe this to have a bearing on the requirements of the post, we will discuss the matter with you at the interview. If we do not raise the record with you it is because we have taken the view that it should not be taken into account in deciding your suitability for the post. If you require further information or have any concerns about filling in this declaration, please contact Aison Gales on 01423 876473.
Signed / Date

Equality of Opportunity Monitoring

Saint Michael's Hospice has an equality of opportunity policy, which recognises and actively promotes the benefits of a diverse workforce and is committed to treating all employees with dignity and respect, regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community.

In order to effectively monitor all stages of the recruitment process to ensure that discrimination does not take place, all applicants are required to complete this form as far as possible and return it with your application form.

Please note that this form will not be included in the information used in the selection process.

Name
Post applied for
Date of Birth / Gender
I would describe my racial origin as : ( please tick the category that applies to you )
Black African / Black Afro-Caribbean / Indian
Pakistani / Chinese / Vietnamese / Bangladeshi
White British / White European / White Irish
Other Ethnic Group (Please specify)

Disability

/ Yes / No

I consider myself to have a disability

I would describe my disability as: / Visual
Physical
Hearing
I am registered disabled at the Job Centre and hold a green card.
Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK? / Yes / No
If yes please provide details
If you are successful in your application, would you require a work permit prior to taking up employment?
Declaration
I confirm that the information on this form is true and correct.
In accordance with the Data Protection Act 1998 I give permission for this personal information to be stored and processed for the purposes of employment and monitoring and for sensitive data to be stored and processed in connection with equal opportunities, health and safety reasons and compliance with the requirements of national standards.
Signed Date