Joseph Weld Hospice

EMPLOYMENT APPLICATION FORM

Please complete in black ink or type

Post applied for:......

Please state where you heard about the vacancy:......

SURNAME: ...... MR/MRS/MISS/MS/OTHER:......
FORENAMES:......
FULL ADDRESS:......
......
...... POSTCODE: ......
HOME TEL. NO: ...... DAY TIME TEL. NO: ......
E-MAIL ADDRESS (Mandatory)......
This email address will be used for future correspondence
Qualifications / School/College/University
CURRENT OR MOST RECENT EMPLOYMENTEmployer’s Name & Address ………………………………………………………….…………………………
…………………………………………………………………………………………………….…………………
Email:......
Job Title ………………………………………………………………………………………….…………………
Date Started ………………………………….……….. Period of Notice ………………………………………
Current Salary ……………………….. Hours worked per week ……………………………………………....
Brief description of duties and responsibilities:

Please continue on separate sheet if necessary

EMPLOYMENT HISTORY (this must be a complete employment history over last 20 years)

Name/address of employer / Job Title / Employed / Reason
for
Leaving
From / Until

Please continue on separate sheet if necessary

Please describe why you are applying for this post and refer to any relevant skills, experience and achievements to support your application.

Please continue on separate sheet if necessary

REHABILITATION OF OFFENDERS ACT 1974

Have you any convictions or are currently the subject of police proceedings in this or any country?
Yes No
As this post is exempt from the above act please give details of any convictions.

PROTECTION OF VULNERABLE ADULTS/PROTECTION OF CHILDREN ACT 1999

Are you or have you ever been the subject of any fitness to practice proceedings by a UK or overseas licensing or regulatory body?
Yes No
REFEREES
Please give the names of two people who are able to provide references relating to your work experience and your suitability for the post applied for. One referee should be your current or most recent employer. Referees may be approached before interview, unless a cross is indicated in the box.
1.Name:......
Position: ......
Address: ......
Email:......
2.Name: ......
Position: ......
Address: ......
Email:......

If successful you will be required to complete a pre-employment Occupational Health questionnaire and a Disclosure & Barring Service check. Any offer of employment will be subject to satisfactory reports from each of these.

Do you require a Work Permit?Yes/No(please delete as appropriate)

If “Yes”, when is expiry date:......

This organisation does not have a policy of obtaining work permits on behalf of applicants.

Tick to confirm you have completed and enclosed Equal Opportunities Monitoring Form as your

application will not be considered without this.

I confirm that, to the best of my knowledge, the information given in this application is accurate and complete.

Signed:...... Date: ......

When completed please return this application form, marked “Confidential” to :

or post to Recruitment, Weldmar Hospicecare,

Hammick House, Bridport Road, Poundbury, DORCHESTER, Dorset DT1 3SD

OFFICE USE ONLY:

DATE RECEIVED: ...... INTERVIEWED:......

P:\People Services\Personnel Forms and Standard letters\Application Forms\Application form - Mar 18.docx