Employment Application Form

Position applying for *

Where did you see the post advertised?

Full name *

Address *

Line 1 *
Line 2
Town *
County
Postcode *
Country

National Insurance Number

Contact telephone number *

Email address *

Do you hold a full current driving licence? *

Are you required to have a permit to work in the UK? *

If yes, what sort of permit do you require?

Employment Record (present or most recent employer first). Please include: Employer’s name and address, Post held and main duties, Dates employed and reasons for leaving, Salary/Benefits *

Notice required by present employer (if applicable):

Education (qualifications obtained from Schools/Colleges/Universities). Please include the name of institution, Qualifications (Academic & Professional). Please give dates for professional qualifications, along with grades

Professional Qualifications; Professional Body, Qualification, Date obtained

Professional Registration Number if applicable (E.g. NMC, GMC)

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? *

If YES please give brief details

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? *

If YES please give brief details

If shortlisted, are there any restrictions on when you could attend for interview? *

If YES, please specify:

Do you know, or are you related to, anyone currently employed by St Luke’s? *

If YES, please give details

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 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.

First referee *

Line 1 *
Line 2
Town *
County
Postcode *
Country

Capacity in which known? *

Referee telephone number

Referee fax number

First referee email address

May we contact this referee prior to interview? *

Second referee *

Line 1 *
Line 2
Town *
County
Postcode *
Country

Capacity in which known? *

Second referee telephone number

Second referee fax number

Second referee email address

May we contact this referee prior to interview? *

Rehabilitation of Offenders Act 1974 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 Quality Care 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? *

If YES please give brief details of offences and penalties, together with dates

Have you ever received a criminal conviction in any country other than the UK? *

If YES please give brief details of offences and penalties, together with dates

Are you currently the subject of any police investigation and/or prosecution, in the UK or any other country? *

If YES please give brief details of offences and penalties, together with dates

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.

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.

Employment Application Form

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