TruroHealthPark, Infirmary Hill, Truro, TR1 2JA

Tel: 01872 246888

Application for Employment

The application form is used by the selection panel to shortlist candidates for interview. The personal information sheets will not be used as part of the shortlisting process. They will be used if you are invited for interview and will form part of your personal file if appointed to the post. Our recruitment and selection procedures follow the data protection principles in accordance with the Data Protection Act 1998.

If you have any queries regarding the completion of your application, please do not hesitate to contact the HR department who will be happy to assist you.

False or misleading information on this form will disqualify you from appointment or if appointed will render you liable to dismissal without notice. The appointment of applicants will be subject to a probationary period, evidence of medical fitness, satisfactory references, proof of qualifications and DBS clearance where appropriate.

Please complete all sections in black ink/type and return completed form to the HR Manager at the above address. All correspondence will be by email, unless directed otherwise.

About the post
Role applied for: / Closing Date:
About you
Surname: / Forename(s):
Previous name(s): / Title:
Home address: / Home phone:
Mobile:
Work phone:
Email:
Postcode:
Date of birth: / NI Number:

May we contact you at work? Yes No

Do you require a work permit to work in the UK? Yes No

If yes, do you have a valid permit?Yes No

Do you hold a current driving licence?Yes No

Equality and Diversity Monitoring Form
The Three Spires Medical Practice is dedicated to promoting equality of opportunity for all and welcomes applications from diverse candidates. For this reason, recruitment and selection procedures have been adopted which aim to preclude any discrimination during consideration of applications for employment. You are requested to provide the following information for statistical monitoring purposes only. Please be assured that this information will be treated as confidential and will not be made available to those persons assessing candidates and making appointments.
Date of Birth
Gender / MaleFemale I do not wish to disclose my gender
Please select the option which best describes your ethnicity (please tick)
Asian
Bangladeshi
Indian
Pakistani
Any other Asian background
Black
African
Caribbean
Any other Black background / Mixed
Asian & White
Black African & White
Black Caribbean & White
Any other mixed background
Other Ethnic Group
Chinese
Any other ethnic group / Undisclosed
I do not wish to disclose my ethnic origin
White
British
Irish
Any other White background
Please select the option which best describes your sexuality (please tick)
Lesbian
Gay
Bisexual / Heterosexual
I do not wish to disclose my sexual orientation
Please select the option which best describes your religion (please tick)
Atheism
Buddhism
Christianity
Hinduism / Islam
Jainism
Judaism / Sikhism
Other
I do not wish to disclose my religion/belief
Disability
The Equality Act 2010 protects people with disabilities, including people with long term health conditions.
Do you consider yourself to have a disability? / Yes I do not wish to disclose this information
No
Please state the type of disability which applies to you. People may experience more than one type of disability, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.
Physical Learning Disability/Difficulty
Sensory Long-standing illness
Mental health condition Other (please state)
Criminal Offences
Have you been convicted by the Courts, cautioned, reprimanded or warned for any criminal offence? / Yes No
Are you currently the subject of any police investigations following allegations made against you? / Yes No
Are you included on either ISA Barred Lists i.e. the Children’s List and the Vulnerable Adults List of individuals considered to be unsuitable for working with children or vulnerable adults? / Yes No
If you have answered ‘yes’ to any of the above questions, details of offences, penalties, dates and country in which they occurred, or of the allegations made against you, must be submitted with your application form in a sealed envelope marked ‘Private and Confidential’ for the attention of the HR Manager, with your name and the post title on.
Criminal Records will only be taken into account for recruitment purposes when the record is relevant. Unless the nature of the work demands it, you will not be asked to disclose convictions which are ‘spent’ under the Rehabilitation of Offenders Act 1974. Having a criminal record will not necessarily bar you from employment, but this will depend on the circumstances and background of your offence(s). If a post is exempt under the Rehabilitation of Offenders Act 1974, you will be notified if selected for interview and asked to disclose all criminal record information, which will include details of ‘spent’ and ‘unspent’ cautions, reprimands, final warnings and convictions. Any post which meets the exemptions will be subject to a DSB check before the appointment is confirmed.
How we protect your personal information
We keep on file information from this application form, equal opportunities form and any documents you attach. This is required for recruitment and equal opportunities monitoring purposes, the payment of staff and the prevention and detection of fraud. All information will be dealt with in accordance with data protection legislation and will not be sold to any third party. Unsuccessful application forms will be destroyed after 12 months; anonymised data will be kept for monitoring purposes.
Your declaration
I understand that any employment, if offered, will be subject to the information on this form being correct and I confirm that no valid information has been wilfully withheld. I understand that if I am appointed, I am liable to dismissal without notice if the information on this form is later proved to be inaccurate.
Signature (applicant): / Date:
Your current or most recent employment
Employer name: / Post held:
Employer address:
Dates employed: / From / To: / Salary:
Reason for leaving:
Main duties and responsibilities:
Previous employment or experience
Start with the most recent first and work backwards. You must explain any gaps in your work history since you left education (e.g. unemployment; career breaks; voluntary work; travel etc).
Dates (mm/yy) / Employer
or
Reason for gap / Job title, duties and responsibilities / Reason for leaving
From / To
Qualifications achieved from secondary, higher and further education
Name of provider / college / Subject / title of qualification / Level and Grade of qualification / Date achieved
(dd/mm/yy)
Other training, courses and self development
Name of provider/college / Title of course/training, e.g. First Aid at Work / Qualification
(if relevant) / Date achieved
(dd/mm/yy)
Membership of professional bodies
Institute or association / Membership level / How obtained, e.g. through qualification or election / Date achieved
(mm/yy)
Your supporting statement
In support of your application, please use the space below (and additional sheets if necessary) to explain why you are applying for the post and how your work experience and personal qualities meet each of the criteria in the person specification. Where possible, please use evidence and examples to support your application.
References
Please provide the details for two employment references, one of which should be your current or most recent employer. Where no employment references are available please provide details of an Educational establishment, Professional Body or Professional Person whom we may contact and who will be able to comment upon your skills and abilities relevant to the post which you have been offered. We cannot accept references from friends or relatives.
Reference 1: / Reference 2:
Name: / Name:
Position: / Position:
Company: / Company:
Address: / Address:
Telephone: / Telephone:
Email: / Email:
Relationship: / Relationship:

For office use only: Candidate Ref. number: