Latham House Medical Practice

Internal Use / Role Ref: / Application Ref:
/ Latham House Medical Practice
Employment Application Form

POSITION APPLIED FOR

Please complete this form in type or black ink. All questions must be answered in the boxes provided.

Post: / Ref: / Closing Date:

PERSONAL DETAILS

Surname: / Title:
Forename(s):
Home address:
Postcode:
Email Address:
Telephone number: / Mobile:
Are you legally eligible for employment in the UK? / YESNO
Do you require a permit to work in the UK? / YESNO
Is your ability to perform the particular job for which you are applying limited in any way? / YESNO
If so, what reasonable adjustments need to be made?
Do you have a relevant current driving licence? / YESNO
Please give details of any driving offences currently under endorsement:
Give details of any criminal convictions that you may have. (This employment is exempt from the provisions of the Rehabilitation of Offenders Act 1974. You are not therefore entitled to withholdinformation requested by the Partners about any previous convictions you may have, even if in other circumstances these would be regarded as ‘spent’ under the Act. You are therefore required to provide this information before starting work. Concealment of such information may result in your dismissal.)
Identity Checks: Please note that for all candidates short-listed for interview, identity checks are mandatory. You will need to bring with you to the interview:

Confirmation of nationality (PASSPORT – Photocopies will not be accepted)
Date of expiry of right to stay in country if not a British National (Photocopies will not be accepted)
Photograph for us to keep on file (Passport size)
Evidence of signature (Passport and Driving Licence or Debit card etc.)

Please date and sign the following statement:
I can confirm that, if short-listed, I will bring to the interview all documents required as detailed above, for checking and photocopying.
Date……………….. Signature ………………………………...
(failure to comply will result in your interview being cancelled and your application being rejected)

EMPLOYMENT

Current/most recent employer:
Address (incl. Post Code):
Date Started: / End Date / Until:
Job Title:
Brief Description of Duties:
Reason for leaving:
Current Salary (Per Annum):

PREVIOUS EMPLOYMENT / CAREER HISTORY

Please provide full employment history starting with the most recent. Please account for any gaps/breaks in employment. If necessary, please continue on a separate sheet of paper.

Name & Address of Employer / From / To / Role & Responsibilities / Reason for Leaving
Month / Year / Month / Year

Please describe any other work you have been involved in, eg voluntary, freelance, project work, etc.

Dates/ Duration / Description

EDUCATION, QUALIFICATIONS & TRAINING

Beginning with the most recent events, give details of your education, qualifications and training to date.

Name of University / College / School / Training Provider / Dates / Qualifications & Skills acquired
From / To

STUDY / TRAINING CURRENTLY BEING UNDERTAKEN

Name of University / College / School / Training Provider / Dates / Qualifications & Skills acquired
From / To

APPRENTICESHIPS, MEMBERSHIPS OF PROFESSIONAL ORGANISATIONS

RELEVANT EXPERIENCE

Having read the job description and person specification, please state how your experience and achievements to date, either through employment or activities outside of work, would make you a suitable candidate for this post. You must address each criteria detailed on the person specification and provide examples of how you meet the criteria. If you need to continue beyond these pages of the form please use the same size white paper.

(If required, please continue on a separate sheet of paper.)
INTERESTS

Give details of your main interests and the depth to which these are pursued.

ADDITIONAL INFORMATION

Are you related to a GP Partner or an employee of Latham House Medical Practice? / YESNO
If so, please provide the name, position and details of the relationship.
Please indicate any dates you are not available for Interview.
When would you be available to take up the appointment?

REFERENCES

Please provide names, addresses and occupations of two referees (not relatives), preferably previous employers, whom we may approach with regard to your application at an appropriate and later date after obtaining your permission. If you are known to your referee by a previous surname, please state the name.

FIRST REFEREE / SECOND REFEREE
Name: / Name:
Occupation: / Occupation:
Relationship: / Relationship:
Address: / Address:
Email Address: / Email Address:
Telephone No: / Telephone No:

Declaration

Any of the above particulars may be subject to check. I understand that any false, inaccurate or incomplete information could result in dismissal, disciplinary action or a withdrawal of any offer of employment.
I declare that the information given on this form is to the best of my knowledge correct and complete and can be treated as part of any subsequent contact of employment.
I understand that Latham House Medical Practice may process, by means of a computer database or otherwise, any information which I provide to it, for the purpose of employment with Latham House Medical Practice.
Please note: If you return this form by e-mail, your signature confirming the above will be requested if you are invited to attend an interview.
Signature:...... Date:......

Official Use Only:

Application form evaluated by:Date:
Shortlisted:YESNOInterview date:
Interview panel1.2.3.
Successfulkeep on filenot successful
Offer details:Start date:£per hourhours per week
Offer letter sent:Confirmation of acceptance received:
References sent for:1.2.
References received:1.2.

Please return in an A4 sized envelope marked ‘CONFIDENTIAL’; to:

Contracts & Performance Manager

Latham House Medical Practice

Sage Cross Street

Melton Mowbray

Leicestershire

LE13 1NX

or email to

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