APPLICATION FORM

 

POST APPLYING FOR:


 

Where did you see this post advertised?


Personal Details

 

Surname:  Forenames:

Address for correspondence:



Telephone Numbers: Work: Home:
 
Mobile: E-mail:

May we contact you at work? We will do so discreetly    Yes No


Nurses only
 
NMC No:      Expiry Date:

Work Permit
Do you need a work permit to work in the UK?    Yes No

Do you have a work permit?    Yes No

Work Permit No:         Expiry date:

Education, Qualifications and Training

Secondary education
School name/address

Dates

Examinations (subject/result)
 

From

To

Further education
University/College

Dates

Course Subject

Qualification
From

To


Professional qualifications

College/Institute
 

Dates

Qualification
 

From

To


Other relevant training
Dates

Course Subject

Place of Training

Result

From

To


Present/Most Recent Employment

 
Name of employer: 

Address: 
Starting date:
Leaving date:
Salary:
Notice required:

Job title:          

Duties: 

Previous Employment (most recent first)

Dates

Name and Address
of Employer

Job Title
and Duties

Reason for Leaving
From To







Experience, Personal Qualities and Skills

Please use this section to indicate how far you meet the requirements of the post. List experience, achievements, knowledge, personal qualities and skills, which you feel are relevant to your application.

Criminal Convictions

All positions at the Hospice are exempt from the provisions of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act (Exceptions) Order 1975, and you are therefore required to disclose all convictions, cautions or bind-overs you have ever received, including those which would otherwise be considered ‘spent’. Having a criminal conviction will not necessarily bar you from working at the Hospice. This will depend on the nature of the position and the circumstances and background of your offence(s).  All applicants who are offered positions which involve working alone or unsupervised with patients, will be subject to a criminal record check (Enhanced Disclosure) from the Criminal Records Bureau before the appointment is confirmed.  The CRB Code of Practice is available to read on application.

Do you have any criminal convictions, cautions or bind-overs?   Yes No

If Yes, please give details with dates:

Referees

Please provide names of two referees, one of which should be your present employer.   Personal referees should only be provided if you have not been in employment or further education during the past 5 years.  These should not be from immediate colleagues but from a professional person know to you for at least two years. 
If you do not wish us to contact your present employer without permission from you, please tick box

Name:   Name:
Relationship:   Relationship:
Address:   Address:
Telephone:   Telephone:

Declaration

I confirm that the information which I have given in this application form is true and complete.  I understand that if it is subsequently discovered that any statement is false or misleading, this may lead to rejection of my application or, if employed, to dismissal.

Please type your signature into the box below.

Signed:   Date:


Equal Opportunities

North London Hospice is committed to preventing discrimination and promoting equality. To enable us to monitor the effectiveness of our equal opportunities policy, we need to obtain certain information from applicants. You are therefore requested to complete this form. This information will be treated as confidential, and will not form part of the shortlisting process. By completing this form, you are agreeing under the Data Protection Act 1998, that the Hospice may hold and use personal information about you for monitoring purposes.

Date of birth:   Age:

Gender: Male Female

Ethnic Origin:

Do you consider yourself to have a disability? Yes No

If yes, what is the nature of your disability?