APPLICATION FORM - PERSONALINFORMATION(CONFIDENTIAL)

1. PersonalDetails

Address:
PostCode:
Contactdetails:(Pleasetickpreferredcontactdetail)
Emailaddress:
Telephone Home: …………………………………………..…… Business: …………………………………………… Mobile: ……………………………………………………..…
National Insurance Number:

2. General

Doyouholdacurrentdrivinglicence?YesNo

IfYes,whichlicenceisitFullProvisionalLGVPCV

Please detail any points on your licence

Date
Offence Code
Offence
Number of Points
Expiry

Disclosure of Criminal Records and Police Clearance

A criminal record will not necessarily exclude you from employment .The information provided will be treated as strictly confidential and will only

be considered in relation to the job for which you are applying. You are required to disclose any ‘unspent’ criminal convictions in line with the

Rehabilitation of Offenders Act 1974.

However, if you are applying for work which involves substantial opportunity for access to children or vulnerable adults, you are required to give

details of criminal convictions, cautions, reprimands or final warnings even if they are regarded as ‘spent’. The amendmentsto the Exceptions

Order 1975 (2013) provide that certainspent convictions and cautions are 'protected' and are not subject to disclosure to employers, and cannot

be taken intoaccount. Guidance and criteria on the filtering of these cautions and convictions can be found at the Disclosure and Barring Service

website you identify that you have a criminal record, this will be discussed in confidence at interview.

Have youever been convicted of a criminal offence which is not ‘protected’?

Yes No

If yes please give brief details:

Disclosure & Barring Service

Posts that may have substantial opportunity for access to children or vulnerable adults are exempt from the Rehabilitation of Offenders Act and will

require a Disclosure & Barring Service check. Successful applicants will be asked to apply for a Disclosure from the Disclosure & Barring Service.

Declaration (for posts that may have substantial opportunity for access to children or vulnerable adults)

In your current, or any previous employment, have you ever been subject to any investigations or disciplinary procedures involving issues related to

the safety and welfare of children, young people or vulnerable adults or your behaviour towards children, young people or vulnerable adults?

Yes No

If “YES”, please provide details below, for example the outcome of the investigations or procedures and whether any penalties that were

applied have now expired:

Are you related to, or closely acquainted with, anySt Rocco’s Trustee or any Member of St Rocco’s staff? Yes No

If so who and in what capacity:

Arethereanyadjustmentsthatmayberequiredtobemadeshouldyoubeinvitedforinterview?
Ifso,pleasestatehere:
St Rocco’s guarantees that, if you consider yourself to have a disability, and you meet the essential requirements of the post, you will be interviewed. If you would like your application to be considered under thisguarantee please tick this box. See the Recruitment Process and Application Guidance Notes for more information.
Pleaseindicatetworeferees who are not related to you,whocanprovidereferences about your suitability for the job. If presently employed, one must be your current employer. If unemployed, one must be your most recent employer. In the absence of previous employment experience a reference from your head teacher / tutor or related to relevant voluntary work is acceptable.
1. Current or most recent employer / 2. Previous employer or Personal referee
Name: / Name:
Address: / Address:
Tel.No. / Tel.No.
Email: / Email:
Occupation: / Occupation:
How long has the referee known you: / How long has the referee known you:
In what capacity does the referee know you? / In what capacity does the referee know you?
Current employer
Most recent employer
Personal (if you do not have previous employment experience) / Previous employer
Colleague/former colleague or manager but the referee is given on a personal basis
Personal
Igive/donotgivepermissiontotakeupmyreferencespriortoanofferofemploymentbeingmade
(Deleteclearlyasappropriate). / Igive/donotgivepermissiontotakeupmyreferencespriortoanofferofemploymentbeingmade
(Deleteclearlyasappropriate).

Availability (Please show your maximum range of working hours availability)

Day / AvailableHours
-StartTime / AvailableHours
-EndTime
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Some roles (such as fundraising) may necessitate out of hours work when required. For more information please refer to the relevant JD and PS.

For part-time roles, what is the minimum and maximum number of hours you are willing to work per week?

Minimum / Maximum

Please give details of any holidays booked in the next six months

Please detail any days / times you are unable to attend interview

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Employmenthistory

Employer (Name & Full Address) / Post Held / Duties & Key Achievements / Dates / Reason for Leaving / gap in employment
From
Mm/yyyy / To
mm/yyyy

Pleasecontinueonaseparate sheetifnecessary,givingpagenumberandtitleheading

Registered Charity No. 511592 Page 1

3.Educational,TechnicalandProfessionalQualifications

Pleasenameanyinstituteorprofessionalbodyinfullandincludeattainmentlevel

Name of qualification / course / Awarding Body / Grade / Details – Full Name and address of School, College, University, Institution and type of study e.g. full time, part time, distance learning / From mm/yyyy / To
mm/yyyy

Pleasecontinueonaseparate sheetifnecessary,givingpagenumberandtitleheading

Can you provide evidence of your qualifications? Yes No

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4.PersonalDevelopment

PersonalDevelopment(includeanycourses,membership,voluntaryworkorresponsibilitiesyouconsiderrelevant,withoutcomeswhereapplicable).

CONTINUING PROFESSIONAL DEVELOPMENT
Other relevant training / courses completed / Dates / Subjects / Course Title / Qualification / Grades
From
mm/yyyy / To
mm/yyyy

Membership of Professional body

Please record any memberships of professional bodies you are currently part of

Body/Organisation / Registration/PIN number / Date of registration

Pleasecontinueonaseparate sheetifnecessary,givingpagenumberandtitleheading

Registered Charity No. 511592 Page 1

RELEVANTSKILLS,KNOWLEDGEANDEXPERIENCE

Inthissectionyouareaskedtooutlinehowyourknowledge,skillsandexperiencesmeetthoserequiredforthisrole(asoutlinedinthe Job Descriptionand Person Specification document).Youshoulddrawonyourexperiencesfromyourcurrentorpreviousrolesorfromotherrelevantsituations(suchasactivitiesoutsidework).

Pleasecontinueonaseparate sheetifnecessary,givingpagenumberandtitleheading

Registered Charity No. 511592 Page 1

ArethereanyrestrictionstoyourresidenceintheUKwhichmightaffectyourrighttotakeupemploymentintheUK?Yes No

IfYes,pleaseprovidedetails:

Ifyouaresuccessfulinyourapplication,wouldyourequireaworkpermitpriortotakingupemployment?Yes No

Immigration, Asylum and Nationality Act 2006UK Immigration legislation, in particular the Immigration, Asylum and Nationality Act 2006, is designed to prevent illegal working in the UK. To prevent illegal working it is necessary that employers carry out document checks on all prospective employees. These checks are required to ensure that employees demonstrate that they are eligible to work in the UK.

Please refer to the enclosed ‘Right to Work Declaration’.

DataProtectionStatement

Declaration

I declare that all the information I have provided is accurate and complete, and I am in agreement with the information provided being processed

within the guidelines of the Data Protection Act 1998. I understand that any false information I have given may result in disqualification from the

selection process or, where discovery is made after appointment, in summary dismissal.

…………………………………………………………………………………………………………………………………………

Please return your completed application and equality (optional) forms to or by post to Human Resources Department, St. Rocco’s Hospice, Lockton Lane, Bewsey, Warrington, WA5 0BWmarked ‘Private and Confidential’.

Registered Charity No. 511592 Page 1

RIGHT TO WORK IN THE UK DECLARATION

I confirm that I have the right to work in the UK and if interviewed will produce one of the following specified documents (or two documents in a specified combination) from list A or list B.

I accept that the documents detailed in list B indicate only that I have a limited right to live and work in the UK and that if my application is successful such documents will require to be checked on an annual basis.

LIST A

  1. An ID card issued under the Identity Cards Act 2006.
  2. A passport showing you are a British subject.
  3. A national identity card or a passport which identifies you as a national of the European Economic Area (EEA) or Switzerland.
  4. A residence permit, registration certificate or document certifying or indicating permanent residence issued to you by the Home Office or the UK Border Agency.
  5. A Biometric Immigration Document issued by the UK Border Agency to you indicating that you are allowed to stay indefinitely in the UK.
  6. A passport or other travel document endorsed to show that you are exempt from immigration control, are allowed to stay indefinitely in the UK, have the right of abode in the UK, or have no time limit on your stay in the UK.

Documents 7 – 10 below are acceptable only if produced in combination with an official document, issued by a government agency or a previous employer, giving your national insurance number and your name.

  1. An Immigration Status Document issued by the Home Office or the UK Border Agency to you with an endorsement indicating that you are allowed to stay indefinitely in the UK.
  2. Your full birth certificate or adoption certificate issued in the UK, the Channel Islands or Ireland, that includes the name(s) of at least one of your parents/adoptive parents.
  3. Your certificate of registration or naturalisation as a British subject.
  4. A letter issued by the Home Office or the UK Border Agency to you that indicating that you are allowed to stay indefinitely in the UK.

LIST B

A passport or travel document endorsed to show that you are allowed to stay in the UK and allowed to do the type of work in question, provided that it does not require the issue of a work permit.

  1. A Biometric Immigration Document issued by the UK Border Agency to you that indicates that you can stay in the UK and are allowed to do the work in question.
  2. A work permit or other approval to take employment, issued by the Home Office or the UK Border Agency. This must be produced in combination with either a passport or another travel document endorsed to show that you are allowed to stay in the UK and allowed to do the work in question, or a letter issued by the Home Office or the UK Border Agency to you confirming that you are allowed to do the work in question.
  3. A certificate of application issued by the Home Office or the UK Border Agency stating that you are permitted to take employment. The certificate of application must be less than six months old and produced in combination with evidence of verification by the UK Border Agency Employer Checking Service.
  4. A residence card or document issued by the Home Office or the UK Border Agency to a family member of a national of an EEA country or Switzerland.
  5. An Application Registration Card issued by the Home Office or the UK Border Agency stating that you are permitted to take employment. This must be produced in combination with evidence of verification by the UK Border Agency Employer Checking Service.
  6. An Immigration Status Document issued by the Home Office or the UK Border Agency to the holder with an endorsement indicating that you can stay in the UK, and are allowed to do the type of work in question. This must be produced in combination in with an official document, issued by a government agency or a previous employer, giving your national insurance number and your name.
  7. A letter issued by the Home Office or the UK Border Agency to the holder or the employer or prospective employer that indicates that the person named in it can stay in the UK and is allowed to do the work in question. This must be produced in combination with an official document, issued by a government or a previous employer, giving your national insurance number and your name.

Signature of Applicant:

Date:

EQUALITY AND DIVERSITY MONITORING FORM

St. Rocco’s Hospice wants to meet the aims and commitments set out in its equality policy. This includes not discriminating under the Equality Act 2010, and building an accurate picture of the make-up of the workforce in encouraging equality and diversity.

The organisation needs your help and co-operation to enable it to do this, but filling in this form is voluntary. The information you provide will stay confidential, and be stored securely and limited to only some staff in the organisation’s Human Resources section.

The form below will be detached from your application form, stored separately and used only to provide statistics for monitoring purposes.

Gender Male  Female  Prefer not to say 

Are you married or in a civil partnership? Yes No  Prefer not to say 

Age16-2425-2930-3435-3940-44 45-4950-5455-59  60-64  65+  Prefer not to say 

What is your ethnicity?

Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong.

Please tick the appropriate box

White

English  Welsh  Scottish  Northern Irish  Irish  British  European  Gypsy or Irish Traveller  Prefer not to say 

Any other white background, please write in:

Mixed/multiple ethnic groups

White and Black Caribbean  White and Black African  White and Asian  Prefer not to say 

Any other mixed background, please write in:

Asian/Asian British

Indian  Pakistani  Bangladeshi  Chinese  Prefer not to say 

Any other Asian background, please write in:

Black/ African/ Caribbean/ Black British

African  Caribbean  Prefer not to say 

Any other Black/African/Caribbean background, please write in:

Other ethnic group

ArabPrefer not to say 

Any other ethnic group, please write in:

Do you consider yourself to have a disability or health condition?

Yes  No  Prefer not to say 

What is the effect or impact of your disability or health condition on your ability to give your best at work?

Please write in here:

The information in this form is for monitoring purposes only. If you believe you need a ‘reasonable adjustment’, then please discuss this with your manager, or the manager running the recruitment process if you are a job applicant.

What is your sexual orientation?

Heterosexual  Gay woman/lesbian  Gay man  Bisexual  Prefer not to say 

If other, please write in:

What is your religion or belief?

No religion or belief  Buddhist  Christian  Hindu  Jewish  Muslim  Sikh  Prefer not to say 

If other religion or belief, please write in:

What is your current working pattern?

Full-time Part-time  Prefer not to say 

What is your flexible working arrangement?

None  Flexi-time  Staggered hours  Term-time hours  Annualised hours  Job-share  Flexible shifts  Compressed hours  Homeworking  Prefer not to say 

If other, please write in:

Do you have caring responsibilities? If yes, please tick all that apply

None  Primary carer of a child/children (under 18)  Primary carer of disabled child/children 

Primary carer of disabled adult (18 and over)  Primary carer of older person 

Secondary carer (another person carries out the main caring role)  Prefer not to say 

Please return your completed application and equality (optional) forms to or by post to Human Resources Department, St. Rocco’s Hospice, Lockton Lane, Bewsey, Warrington, WA5 0BWmarked ‘Private and Confidential’.

Registered Charity No. 511592 Page 1