APPLICATION FORM: - CLINICAL POST

a) Position applied for and Job Reference: Accredited Primary Care Counsellor - Derby

06PCCD17

Where you saw the position advertised:

Personal Information

Details entered in this part of the form will be held in the HR department of the recruiting organisation. Access to this information will be withheld from the short-listing panel.

Please do not type in capital letters, use the appropriate mixture of capital and lowercase in standard written text. Submitting your application in capital letters could lead to your application being automatically rejected.

b) Personal Details

Title: /
First name: / Preferred Name:
Middle name(s): /
Surname name: /
Name in which you are registered with
a professional body: (if applicable) /
UK National Insurance Number: /
Address: /
Postcode: /
Home Telephone Number: /
Mobile Telephone Number: /
Work Telephone Number: /
(only quote if we can contact you on this)

E- Mail Address:

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c) Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National?
Yes / No

If you have answered “No” above, you must answer these questions:

Please select the category that relates to your current immigration status. This status will be subject to checking before interview.
Indefinite leave to remain / Refugee
Highly Skilled Migrant Programme / Tier 1 / Visitor
Work Permit / Tier 2 / Post graduate doctors and dentists
Dependant / Spouse Visa / Tier 5 Temporary Workers
Working Holiday Visa / Tier 5 Youth Mobility / Students
Clinical Attachment Visa / Other – Please specify below:
Does your visa have a condition restricting employment or occupation in the UK?
Yes / No
Please supply details of any visa currently held, number, start/expiry dates and details of any restrictions:
Visa №: /
Start Date (DD/MM/YYYY): /
Expiry Date (DD/MM/YYYY): /
Details of Restriction: /


Criminal Convictions

d) Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions after the rehabilitation period set by the court has elapsed and the convictions become "spent". During the rehabilitation period, convictions are referred to as "unspent" convictions and must be declared to employers.

Before you can be considered for appointment with Trent PTS we need to be satisfied about your character and suitability.

Trent PTS aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion or belief, disability, sexual orientation and age.

Trent PTS undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.

Have you any unspent criminal convictions or bind-overs, or any cautions, warnings or reprimands?

Yes / No

If “Yes”, please give details on a separate sheet of paper.

If you are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory disclosure from the Disclosure and Barring Service. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment. Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. 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.

In order to protect certain vulnerable groups within society, there are a number of posts within Trent PTS that are exempt from the provisions of the Rehabilitation of Offenders Act 1974. These include positions where there is access to patients in the course of normal duties. As the post you have applied for falls within this category, it will be exempt from the provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975.

Applicants for such posts are not entitled to withhold any information about convictions, cautions, warnings and reprimands which for other purposes are "spent" under the provisions of the Act. If you are successful with this application, any failure to disclose such information could result in dismissal or disciplinary action. Any information provided will be confidential and will be considered only in relation to posts to which the order applies. A check will be made with the Disclosure and Barring Service.

Have you at any time received or had pending a criminal conviction, caution, warning, reprimand or bind-over?

Yes / No

If “Yes”, please give details on a separate sheet of paper.

Are you barred from working with children?

Yes / No

Are you barred from working with adults?

Yes / No

Qualifications

Details entered in this part of the form will be held in the HR department of the recruiting organisation and will be made available to the short-listing panel.

e) Education & Professional Qualifications

All qualifications disclosed will be subject to a satisfactory check.

Include in this section all the relevant qualifications. Please also indicate subjects currently being studied. All qualifications disclosed will be subject to a satisfactory check.

Subject/Qualification / Place of study / Grade/Result / Year Obtained

f) Training Courses Attended

Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking, together with the date completed or to be completed.

Course title / Training provider / Duration / Year Obtained


g) Membership of professional bodies

Please indicate your UK professional registration status:

I have current UK professional registration / UK professional registration required and applied for
I do not have the relevant UK professional registration / UK professional registration required but not applied for
I am a student

If professional registration is not required then go to Employment History.

If you answered "I have current UK registration" then please enter the relevant details below.

PLEASE STATE IF YOU ARE ACCREDITED
Membership/Registration number / Expiry/Renewal Date
BACP /
/
BABCP /
/
British Psychological Society /
/
General Social Care Council /
/
Health Profs. Council /
/
NMC /
/
UKCP /
/
Other – Please give details: /
/

If applicable, please provide details of any conditions/restrictions you may have.

Are you currently the subject of a fitness to practise investigation or proceedings by a licensing or regulatory body in the UK or in any other country?

Yes / No

Have you been removed from the register or have conditions been made on your registration by a fitness to practise committee or the licensing or regulatory body in the UK or in any other country?

Yes / No

h) Employment History

Please record below the details of your previous employment, beginning with the most recent first. If required, please provide additional information regarding your employment history within the 'Supporting Information' section.

Current/Most Recent Employer
Employer name: /
Employer Address/Telephone Number:
/
Job Title: /
/ Grade: /
/ Salary: /
Start Date: /
/ End Date: /
Period of notice /
Reason for leaving (if applicable):
Brief description of your duties and responsibilities:
Employer 2
Employer name: /
Employer Address/Telephone Number:
/
Job Title: /
/ Grade: /
/ Salary: /
Start Date: /
/ End Date: /
Reason for leaving (if applicable):
Brief description of your duties and responsibilities:
Employer 3
Employer name: /
Employer Address/Telephone Number:
/
Job Title: /
/ Grade: /
/ Salary: /
Start Date: /
/ End Date: /
Reason for leaving (if applicable):
Brief description of your duties and responsibilities:
Employer 4
Employer name: /
Employer Address/Telephone Number:
/
Job Title: /
/ Grade: /
/ Salary: /
Start Date: /
/ End Date: /
Reason for leaving (if applicable):
Brief description of your duties and responsibilities:

If necessary, please continue on a separate sheet of paper.

If you have any gaps within your employment history, please state below:

i)  Supporting Information

Please give your reasons for applying for this post and additional information which shows how you match the person specification. This can include relevant skills, knowledge, experience, voluntary activities and training etc.

If relevant to the post for which you are applying, you should include details about research experience, publications or poster presentations, clinical care (knowledge and skills) and clinical audit.

j) Additional Personal Information

Do you have access to a vehicle which can be used for work purposes?

Yes / No

Do you have a valid driving licence for the UK?

Yes / No

k) References

Please give the names and addresses of two separate professional referees who can comment on your suitability for this appointment. You should include your present or most recent employer.

Referee 1
Title: /
/ First Name: /
/ Surname: /
Address: /
Postcode: /
Telephone Number: /
Email Address: /
Relationship: /
Can the referee be approached prior to interview? / Yes No No
Referee 2
Title: /
/ First Name: /
/ Surname: /
Address: /
Postcode: /
Telephone Number: /
Email Address: /
Relationship: /
Can the referee be approached prior to interview? /
Yes / No

l) Availability

When would you be available to take up the appointment?......

m) Declaration

It is the Company’s policy to employ the best qualified personnel and provide equal opportunity for the advancement of employees including promotion and training and not to discriminate against any person because of race, colour, national origin, sex, sexual orientation, age, religion or belief or marital status or disability.

I declare to the best of my knowledge and beliefs, all particulars I have given are complete and true. I understand that any false declaration or misleading statement or a significant omission statement may disqualify me from employment and render me liable to dismissal.

I also understand that any job offer is subject to references, DBS Check, qualification check and a probationary period, all of which must be deemed by the Company satisfactory.

Where applicable, I consent that the organisation can seek clarification regarding qualifications/professional registration details.

Signed...... Date......

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