ࡱ> u@ bjbj '@0S0S0S8hS|T4U](]]]gjYl $/RhD,oge g,o,oD]]i=ooo,o:]]o,ooo pֈ]U ʭR0SfovrS0\o0p5mm^onLcn5m5m5mDD%l-%ol-ST LUKES HOSPICE KENTON GRANGE, KENTON ROAD, HARROW, MIDDX HA3 0YG JOB APPLICATION FORM To complete this form, please click in the grey spaces and either choose from the drop-down options or type the information. This is a Word template. When complete, save the result as a Word document and send it to St Lukes as an e-mail attachment Title of post:  FORMTEXT       Closing date:  FORMTEXT       Where did you see the post advertised?:  FORMTEXT          Personal Details Surname:  FORMTEXT       First Name(s):  FORMTEXT      Title:  FORMTEXT       Address:  FORMTEXT       Post Code  FORMTEXT       National Insurance No: FORMTEXT       Home telephone no:  FORMTEXT       May we contact you at work?  FORMDROPDOWN  E-mail:  FORMTEXT       Work telephone no:  FORMTEXT       Do you hold a full current driving licence?  FORMDROPDOWN  Are you required to have a permit to work in the UK?  FORMDROPDOWN  If yes, what sort of permit do you require?  FORMTEXT        Health: please give details of any period of illness which has caused you to be absent from work for more than three consecutive days in the past two years:  FORMTEXT       Employment Record (present or most recent employer first) Please complete all sections for your most recent ten posts Employer s name and addressPost held and main dutiesDates employed and reasons for leavingSalary/ Benefits FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Notice required by present employer (if applicable)  FORMTEXT       Education (qualifications obtained from Schools/Colleges/Universities) Please enter the most recent five  Name of institutionQualifications (Academic & Professional) Please give dates for professional qualificationsGrades FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        Professional Qualifications Professional BodyQualificationDate obtained FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Professional Registration Number if applicable (E.g. NMC, GMC) :  FORMTEXT       If applicable, are you currently the subject of any investigation or proceedings by any body having regulatory functions in relation to health/social care professionals, including such a regulatory body in another country?  FORMDROPDOWN  If YES please give brief details:  FORMTEXT       If applicable, have you ever been disqualified from the practice of a profession or required to practice it subject to specific limitations following a fitness to practice investigation by a regulatory body in the UK or another country?  FORMDROPDOWN  If YES please give brief details:  FORMTEXT       Interviews (if you are shortlisted)  Are there any restrictions on when you could attend for interview?  FORMDROPDOWN  If yes, please specify:  FORMTEXT        Connections: Do you know, or are you related to, anyone currently employed by St Luke s?  FORMDROPDOWN  If so, please give details:  FORMTEXT       Supporting Statement  Before completing this section, please read the Job Description carefully. The shortlisting process will involve looking at how you meet the skills required. Therefore, please demonstrate how you meet the requirements, by giving relevant details of the skills, experience, and knowledge that you have gained in employment, voluntary work or elsewhere, and also explain why this particular post interests you. Please continue onto the next page if necessary but, please, no further than that.  FORMTEXT       References  Please give the names, positions and addresses of two referees, one of two people who are able to provide references relating to your work experience and suitability for the post applied for. One referee should be your current or most recent employer. 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FORMDROPDOWN   Name:  FORMTEXT       Position:  FORMTEXT       Address:  FORMTEXT       Post Code:  FORMTEXT       Tel No:  FORMTEXT       email  FORMTEXT       *May we contact before interview?  FORMDROPDOWN    Rehabilitation of Offenders Act 1974  CRIMINAL CONVICTIONS, CAUTIONS OR BOUND OVER ORDERS Posts entailing (or potentially) entailing contact with patients are exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1975, by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants are therefore not entitled to withhold information about anything on their criminal record (convictions, cautions, bind-overs, reprimands or final warnings), however long ago these occurred, and, which for other purposes, are  spent under the provisions of the Act. In the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by the hospice. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the Order applies. Only relevant convictions and other information will be taken into account so disclosure need not necessarily be a bar to obtaining this position. If you have declared a criminal record and we believe this to have a bearing on the requirements of the post, we will discuss the matter with you at interview. If we do not raise the record with you, it is because we have taken the view that it should not be taken into account in deciding your suitability for the post. Under the rules of the National Care Standards Commission, all new recruits are routinely screened by the Criminal Records Bureau (either to a Standard or Enhanced level, depending on the post). Any appointment is conditional upon receiving satisfactory clearance. Failure to receive this clearance, or any discrepancy with information declared on the application form, may lead to the withdrawal of any offer, or to summary dismissal. Have you ever been convicted by the courts (either spent or unspent convictions), or cautioned, reprimanded, or given a final warning by the police?  FORMDROPDOWN  If YES please give brief details of offences and penalties, together with dates:  FORMTEXT       Have you ever received a criminal conviction in any country other than the UK?  FORMDROPDOWN  If YES please give brief details of offences and penalties, together with dates:  FORMTEXT        Are you currently the subject of any police investigation and/or prosecution, in the UK or any other country?  FORMDROPDOWN  If YES please give brief details of offences and penalties, together with dates:  FORMTEXT       The information you give will be kept confidential. The Data Protection Act requires that personal information be obtained and processed fairly and lawfully; only be disclosed in appropriate circumstances; be accurate, relevant, not held longer than necessary, and be kept securely. By submitting an application for employment, you are consenting to the recording and use of the information that you supply, (for example, your age, sex and ethnic origin), so that we can monitor our compliance with the law, and best practice in terms of equal opportunity and non-discrimination. Date of completion:  FORMTEXT        **Please ensure you read the  Additional Information for Candidates page on this website, ** You will be required to sign a printed copy of this form at interview I confirm that the details I have supplied above are correct and complete and I understand that St. Luke s Hospice has the right to terminate my employment, or cancel any agreements made, in the event that it is discovered that the information provided is not accurate, or is misleading in some material way. As St Luke s Hospice meets the requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974, I understand that, should I be offered employment, it will be subject to a criminal record check (either a Standard or Enhanced Disclosure depending on my position), from the Criminal Records Bureau, before the appointment is confirmed. This will include details of cautions, reprimands or final warnings, as well as convictions. Signature & & & & & & & & & & & & & & & & & & & & & & Date: & & & & & & & & & & & & & & & & & & & .  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