Job Application - St Elizabeth Hospice

Recruitment: Job Application Form

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Vacancy Title

Personal details

First Name*

Middle Name

Last Name*

Address*

Street Address* Address Line 2 Town* County* Postcode* Country

Telephone No. (Home)

Mobile*

Email*

Enter Email* Confirm Email*

Preferred Pronouns

He/Him

She/Her

They/Them

Other

How did you hear about this vacancy?*

Do you require a permit to work in the UK?*

Yes

If yes, do you already have this in place?

Yes

If yes, enter date of expiry

Day

Month

Year

Do you have a family member that works for the hospice?*

Yes

If yes, where do they work?*

What is their name & job title?*

Do you currently hold a UK driving license?*

Yes

Have you had any driving convictions or endorsements?*

Yes

If yes, please specify*

Do you consider yourself to have any disabilities which may affect your application?*

Yes

If yes, please specify*

Please describe such disabilities below, providing details of:- Any reasonable adjustments which you feel should be made to the recruitment process to assist you in your application for the job. Any reasonable adjustments which you feel should be made to the job itself which would enable you to carry out the job.

Employment History

Please start with your present or most recent employment and work backwards. Include periods of unemployment and self employment. Any discrepancies/gaps in employment dates will be investigated.

Employment history*

Employer

Date From

Date To

Position held

Reason for leaving

Current or most recent salary

Secondary & Further Education

Please list all relevant secondary & further education qualifications below. Please enter in qualifications in date order beginning with the most recent.

Education

Please list all relevant secondary & further education qualifications below. Please enter in qualifications in date order beginning with the most recent.

Institution

Date From

Date to

Qualification

Grade

Please give below any professional registration number required in order for you to practise:

Professional/vocational qualifications – relevant for the post being applied for

Professional/Vocational Qualifications

Please list all relevant Professional/Vocational qualifications below.

Qualifications gained

Dates Obtained

Awarding/Statutory Body

Registration No.

Other courses

Courses completed and on going studies

Year

Professional registration information

Please give below any professional registration number required in order for you to practise:

NMC:

GMC:

Other:

Date last re-registered:

Renewal Date:

For Doctors only:

Name of current responsible officer:

Name of organisations that you have a prescribed connection with:

Personal Statement

Personal statement

Please use this section to evidence how you meet the criteria within the person specification. We would ask you to use each section of the person specification as a heading. Please use this section to address all criteria by detailing things you have been responsible for and have achieved. Please give examples from your paid or unpaid work or any other relevant activities. A decision to shortlist can only be based on the information provided within this personal statement.

References

Please state below the names and addresses of two referees (including your current or last employer) and covering at least five years of employment. Referees should not be relatives or personal friends. We reserve the right to contact any previous employer or education establishment mentioned on this application. Please note that it is hospice policy to not offer a formal start date until two satisfactory references have been received. We will however not contact any referees until you have given us permission.

Reference one

Name

Job title

Organisation

Address

Telephone

Reference two

Name

Job title

Organisation

Address

Telephone

Criminal convictions/Probity declaration

Because of the nature of the work undertaken by St Elizabeth Hospice, we require you to answer the following questions. In the event of employment, any failure to disclose such convictions could result disciplinary action or dismissal by the Hospice. Any information given will be completely confidential.

Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198 as set out at http://www.legislation.gov.uk/uksi/2013/1198/pdfs/uksi_20131198_en.pdf.

Convictions?

Yes

Have you ever been disqualified from the practice of a profession or required to practise under specific limitations?

Convictions?

Yes

Are you the subject of any current investigation or proceedings by a professional or regulatory body in the UK or any other country?

Subject of any current investigation?

Yes

Has your employment or contract ever been terminated or suspended – in the UK or abroad – on grounds relating to your fitness to practise (conduct or performance)?

Contract ever been terminated?

Yes

Data Protection Act 1998 and General Data Protection Regulations 2018

This application form has been designed to provide us with sufficient basic information to carry out a preliminary assessment of your suitability for the post. The information you supply in this form is confidential and will only be used by those involved in the appointment in line with the Data Protection Act 1998 and the General Data Protection Regulations 2018. For further information please refer to the GDPR information for job applicants and the hospice’s privacy notice which can be found on the website.

Declaration

I confirm

By ticking above, I confirm that the information given on this form is, to the best of my knowledge, complete and correct. I understand that any incorrect or incomplete information may lead to my application being refused, my offer of employment being withdrawn, or termination of my employment should I have commenced work