Job Application

Title of post*

Where did you see the post advertised?*

Name*

Prefix First Last

Address*

Address Post code

Email*

Phone*

NI Number

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

Details*

Do you hold a current UK Driving Licence?*

Do you have you any convictions or endorsements?*

Employment History*

Please include unemployment, self employment and military service. Any discrepancies/gaps in dates will be investigated.

Employer name and address

Post held and main duties

Dates and reasons for leaving

Salary/ Benefits

Education*

(qualifications obtained from Schools/Colleges/Universities)

Name of institution

Qualifications (Academic & Professional) Please give dates for professional qualifications

Grades

Clinical Staff Only

Pin No.

GMC No.

Date last re-registered

Renewal Date

Supporting Statement*

Before completing this section, please read the Job Description carefully. 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.

References

Please give the names, positions and addresses of two referees. One referee should be your current or most recent employer. Referees will be approached before interview unless a cross is entered in the boxes.

Reference 1 Name*

First Last

Reference 1 Email*

Reference 1 Phone Number*

Reference 1 Address*

Address Postcode Country

Can we contact Reference 1 before the interview?*

Reference 2 Name*

First Last

Reference 2 Email*

Reference 2 Phone Number*

Reference 2 Address*

Address Postcode Country

Can we contact Reference 2 before the interview?*

Criminal Convictions / Probity Declaration

Do you have any criminal convictions that have not become spent under the Rehabilitation of Offenders Act 1974 and/or any offences for which you are currently awaiting a court appearance?*

Details*

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

Details*

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

Details*

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

Details*

Additional Info

Are there any restrictions on when you could attend for interview?*

Details*

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

Details*

Data Protection Act

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 2018

Declaration

I am submitting this application as confirmation 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 my immediate dismissal should I have entered the Hospice’s service.

Date of Application*

References

Criminal Convictions / Probity Declaration

Additional Info

Data Protection Act

Declaration

Equality and diversity monitoring form

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