Strathgryffe Medical Practice

Application Form

Position applied for ……………………………………………………….Date ……April 2018……………

PERSONAL DETAILS
Full Name
Address
Phone Numbers / Landline / Mobile
Email Address
EMPLOYMENT HISTORY
Present/Last Employer
Name
Address
Dates of Employment
Position Held
Main Duties, Responsibilities & Achievements
Reason for Leaving/
Wishing to Leave
Previous Employer
Name
Address
Dates of Employment
Position Held
Main Duties, Responsibilities & Achievements
Reason for Leaving
Previous Employer
Name
Address
Dates of Employment
Position Held
Main Duties, Responsibilities & Achievements
Reason for Leaving
Please include details of any previous employment on a separate sheet.
EDUCATION
School Attended
Qualifications
University/College Attended
Qualifications
Further Education
Qualifications
Please include details of any other educational attainments on a separate sheet.
IT SKILLS
Please list details of IT applications used, including level of competence
Application / Average / Good / Excellent
WORKING HOURS
The hours of work are:
 8.30am – 1.00pm, or
 1.00pm – 5.30pm or 1.30pm – 6.00pm
It is necessary for staff to be flexible to cover absences and we may occasionally ask staff to work a full day, although as much notice as possible will be given. Please advise if any of the above shift times are unsuitable for you.
OUTSIDE INTERESTS
OTHER INFORMATION
Please provide any further information in support of your application, including your reasons for applying for this part-time position. Please continue on a separate sheet if necessary.
REFERENCES
Please provide details of two referees, one of whom should be your present or most recent employer. Family members and friends are not suitable. We will not contact your referees without your permission.
1. Name
Position
Telephone Numbers / Landline / Mobile
Email Address
2. Name
Position
Telephone Numbers / Landline / Mobile
Email Address
DISABILITY
If you have a disability, please tell us about any adjustments we may need to make to assist you at interview.

I confirm that to the best of my knowledge the above information is correct. I accept that providing deliberately false information could result in my dismissal.

Signed ………………………………….… (please type name)Date ………………………………………………..

Please send the completed application form to: Anne Findlay, Practice Manager, Strathgryffe Medical Practice, The Surgery, Kirk Road, Houston PA6 7AR, or email by the closing date of 16 April 2018.