TDL Staff Application Form April 2010 PAGE 5

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APPLICATION FOR EMPLOYMENT

All online applications for employment shouldbe emailedto and postal
applications sent to Human Resources Department, The Doctors Laboratory, 60 Whitfield Street,
London W1T 4EU.

The information supplied on this form may be entered into a database but it will not be disclosed to anyone outside this company.

ALL SECTIONS OF THIS FORM SHOULD BE COMPLETED.

Please state the job title and department for which this application is made.

Job title:
Department:

Personal Details

Surname
First name(s):
By what name do you prefer to be known?:
Title (Mr, Mrs, Miss, Ms, Dr etc.):
Address:
Postcode:
Telephone number (Home):
Telephone number (Work/Daytime):
Telephone number (Mobile):
Email address:

If we need to contact you on your work telephone number we will take into account the fact that your employer or colleagues may not know that you have applied elsewhere for a job.

WHILSTYOUR CV MUST BE PROVIDED, ALL SECTIONS OF THIS FORM MUST ALSO BE COMPLETED.

Any offer of employment is conditional until satisfactory documents providing evidence of the right to work in the UK have been produced. This condition applies to all employees including British citizens. It is a legal requirement to produce a current passport / visa / work permit with supporting documentation BEFORE joining the company.

Qualifications & Training

Starting with the most recent, please give details of your education, qualifications and any training relevant

to this application.

Dates From / To / School / College / Organisation / Details of Qualification / Training / Education

If applicable, please state:

HPC (Health Professions Council) Registration Number


Employment History

Starting with your present or most recent job, please give a summary of all employment, including any

freelance and relevant unpaid work.

Time in this job
Dates from and to / Name of employer, size and nature of their business / Job title, Salary and Benefits,
and any relevant details about the role


Skills, Abilities and Experience

Please use this space to outline the skills and experience you have gained whether in paid or unpaid/voluntary work, work at home, through your studies or your leisure activities and which you think are

relevant to the job for which you are applying and which you believe make you suitable for the post.

CRB Disclosure

You may require a CRB (Criminal Record Bureau) Standard Disclosure Certificate for your employment with us. If you have a recent certificate (less than three months old) please provide a copy with this application.

Where did you hear about this vacancy?
(If you heard through a current employee of
the Company please give their name)
What notice period are you required to
give in your present job?
Do you have any unspent criminal
convictions (as defined under the
Rehabilitation of Offenders Act 1974)?
/ Yes / No
If YES, you may provide details here or,
alternatively, provide details on a separate
sheet of paper which should be placed in
an enveloped marked ‘Confidential – for the
attention of the Head of Human Resources’.


References

We will require you to provide the names and addresses of two referees which apply to the last five years of your employment and/or education. One of these must be from your current or most recent employment. Personal referees will only be accepted when there is no previous employer or educational establishment able to provide a reference.

References that are deemed satisfactory to us must be received before a Contract of Employment is issued, and your employment will not be confirmed until all references are received.

IMPORTANT – YOU MUST SUBMIT TWO REFEREES DETAILS

FIRST REFEREE (All lines must be completed in full)

Name:
Company:
Position:
Address:
Postcode:
Telephone number:

SECOND REFEREE (All lines must be completed in full)

Name:
Company:
Position:
Address:
Postcode:
Telephone number:


Please note that references cannot be sought by e-mail or telephone as original signed statements

are the only acceptable format.

I agree that any offer of employment made by the Doctors Laboratory Limited is subject always to the receipt of two references that are satisfactory to us, plus the evidence of right to work in the UK and for certain positions, a criminal record bureau (CRB) Disclosure certificate. I confirm that the information supplied by me on this form is true and correct.

Signature:
Date:


Equal Opportunities Monitoring

The Doctors Laboratory Limited are committed to equal opportunities for all, irrespective of race, colour,

creed, ethnic origin, gender, marital status, sexuality, disability or age.

So that we can monitor the implementation of this policy it would greatly assist us if you would

complete this monitoring slip.

The information provided will be treated in the strictest confidence and will be used only for statistical

purposes. It will not be used as part of the selection process and will be separated from the application form.

PLEASE TICK ALL BOXES THAT APPLY TO YOU.

GENDER

Male / Female

ETHNIC ORIGIN

African / Asian / Caribbean / White European
Chinese / Asian/UK / Carribean/UK / White Other
Other (Please specify):

AGE BAND

18-24 / 25-34 / 35-44 / 45-54 / 55-60 / 60+

DISABILITY

Do you consider yourself to have a disability? / Yes / No

Thank you for taking time to complete this form.

The Doctors Laboratory Limited

60 Whitfield Street, London W1T 4EU. Tel: 020 7307 7373 Fax: 020 7307 7374
E-mail: Web: www.tdlpathology.com

The Doctors Laboratory Limited is a member of the Sonic Healthcare Limited group of companies. TAP1301/07-12-10/V2