Ambulance Car Service (Acs) & Volunteer Porter Service (Vps)

AMBULANCE CAR SERVICE (ACS) & VOLUNTEER PORTER SERVICE (VPS)

APPLICATION FORM

If you are applying for ACS please complete ALL sections:

If you are applying for VPS please complete sections 1, 4, 5, 6, 8, 9 & 10

Section 1 / PERSONAL DETAILS
Title: Mr / Mrs / Ms or Other – please specify: ………………………………………………………………
Surname: ………………………………………………………………………………………………………..
Forename(s): ……………………………………………………………………………………………………
Address: ……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
…………………………………………………………………………………………………....
Postcode: …………………………………………………….
Home Telephone Number: (inc. STD Code) …………………………Fax No......
Mobile Telephone Number: ………………………….…………….
Email Address: ………………………………………………………………………………………………..
Date of Birth: ……………………………… National Insurance Number: …………………………………..
Section 2 / CAR DETAILS – CAR MUST BE LESS THAN 7 YEARS OLD
(Unless otherwise authorised by managers discretion)
Car Reg Number: ………………………… Make & Model: ……………………………………………….
Cubic Capacity: ………………………….. Seating Capacity: …………………………………………….
Year of Registration: ……………………. Insurance Company: ………………………………………...
Policy Number: …………………………… Insurance Renewal Date: …………………………………...
MOT Certificate Date: ……………………………………………………………………………………….....
Section 3 / DRIVING DETAILS
Driver Number: ……………………………………… Issue Number: ……………………………………
Type of License : Full / Provisional
Valid from: …………………………………… to: ………………………………………………………......
Motor Vehicle Groups / Categories: ………………………………………………………………………...
Date First Passed UK Driving Test: ………………………………………………………………………...
Types of Vehicles Driven: ……………………………………………………………………………………
Endorsements: YES/NO Details if any: ……………………………………………………………………
Court Code: ………………………………. Date of Conviction: …………………………………………..
Offence Code: …………………………….. Date of Offence: ………………………………………………
Disqualification Period: ……………………………………………………………………………………….
Signature: ………………………………………………………………………………………………………..
Section 4 / WORK EXPERIENCE

Please list your work experience for the past 3 years beginning with your most recent job held.

If you were self-employed, give firm name. (Please use additional sheet if necessary).

Name of Employer:
Address:
Phone Number: / Employment Dates From: / Employment Dates To:?
Your last job title:
Description of Duties:
Reason for Leaving:
Name of Employer:
Address:
Phone Number: / Employment Dates From: / Employment Dates To:?
Your last job title:
Description of Duties:
Reason for Leaving:
Name of Employer:
Address:
Phone Number: / Employment Dates From: / Employment Dates To:?
Your last job title:
Description of Duties:
Reason for Leaving:
Section 5 / AVAILABILITY

Please indicate below when you will normally be available:

Days / Before 8am / AM / PM / After 6pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Section 6 / REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the Trusts business and the journeys you will be carrying out, this voluntary post is exempt from the Provision 4 (2) of the rehabilitation of Offenders Act 1974 (Exemptions) Order 1975. Applicants are therefore not entitled to withhold information about convictions which for other purposes are “spent” under the provisions of the Act.

In the event of acceptance as a volunteer, any failure to disclose such convictions will result in termination of use as a volunteer. Any information given will be completely confidential and will be considered only in relation to an n application for positions to which the Order applies.

Have you any previous cautions, convictions or any hearings pending? YES/NO

If yes, please give details:

Section 7 / DISCLOSURE AND BARRINGSERVICE (DBS)

The North East Ambulance Service NHS Trust uses the Disclosure and Barring Service (DBS) to help assess the suitability of applicants for positions of trust. As an organisation we comply fully with the DBS Code of Practice regarding the correct handling, use, storage, retention and disposal of Disclosures and disclosure information. It also complies fully with its obligations under the Data Protection Act and other relevant legislation pertaining to the safe handling, use, storage, retention and disposal of Disclosure information and has a written policy on these matters, which is available to those who wish to see it on request.

Section 8 / PROTECTION OF CHILDREN: DISCLOSURE OF CRIMINAL BACKGROUND OF THOSE WITH ACCESS TO CHILDREN

I understand that the voluntary post for which I am applying is regarded as having access to children.

I understand that the DBS check on any convictions, bind over’s or cautions will be necessary.

I hereby give permission to this check being carried out.

I hereby understand that any information received from the DBS will be treated in absolute confidence.

Signed:......

Date:......

Section 9 / DECLARATION

I have fully read and understood the information regarding the Ambulance Car Service/Volunteer Porter Service and consider that I fulfil all the criteria therein.

I accept that the North East Ambulance Service NHS Trust accepts no liability for damages or injuries to myself, the patients carried or my car, from accidents incurred whilst on duty, and confirm that I have fully comprehensive insurance against such claims or liabilities.

I must notify the North East Ambulance Service NHS Trust of any change of car or insurance arrangements.

I must notify the North East Ambulance Service of any Driving Licence endorsements obtained either prior or subsequent to my joining the service and report any pending prosecution at any time.

I understand that this is a voluntary role and that there are no contractual arrangements or contract of employment stated or implied.

Signed:...... Date:......

Section 10 / REFERENCES

We MUST receive two satisfactory references to proceed with your application. These must be from your most recent employers; if you do not have 2 previous employers a Character reference will be required.

Please give details of 1st Referee:-

Name......

Company and Position……………………………………………………………………………………………..

Address......

......

Telephone Number......

Email address……………………………………………………………………………

Please give details of 2nd Referee:-

Name......

Company and Position……………………………………………………………………………………………..

Address......

......

Telephone Number......

Email address……………………………………………………………………………

Please return completed application form to:

Business Improvement Team (PTS), FREEPOST RRST - KYJC – UYHL, North East Ambulance Service Foundation Trust, Bernicia House, The Waterfront, Goldcrest Way, Newcastle Upon Tyne, NE15 8NY

If you need to add any further information please use the continuation sheet.

Section 11 / CONTINUATION SHEET

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

…

……………………………………………

Equal Opportunities Monitoring

NHS organisations recognise the benefits of having a diverse workforce and therefore welcome applications from all sections of the community. In addition to this, under the provisions of the Equality Act 2010, all NHS organisations are required to demonstrate that their recruitment processes are fair and that they are not discriminating against or disadvantaging anyone because of their age, disability, gender reassignment status, marriage or civil partnership status, pregnancy or maternity, race, religion or belief, sex or sexual orientation. Therefore a series of questions need to be raised in order to ascertain who is applying for each position and to ensure that no one is being unfairly discriminated against or disadvantaged.
This section of the application form will be detached from your application and will not be used as part of the selection process nor will it be seen by anybody who is interviewing you. The information collected is only used for monitoring purposes in an anonymised format to assist the organisation in analysing the profile and make up of individuals who apply, are shortlisted for and appointed to each vacancy. In this way, they can check that they are complying with the Equality Act 2010.

Equality Act 2010

The Equality Act 2010 protects people against discrimination on the grounds of:

their age and sex.
their race which includes colour, nationality, ethnic or national origin.
their religion or belief, including a lack of any belief.
their sexual orientation, be it bisexual, gay, heterosexual and lesbian.

The Equality Act 2010 also protects people who are married or in a civil partnership.

Please choose the categories below which best describes you

Age /  (under 18)  ( 19–35)  (36–50)  ( 51–65 )  (Over 65)
 I do not wish to disclose this
Gender /  Male  Female
I would describe my ethnic origin as:
Asian or Asian British
 Bangladeshi
 Indian
 Pakistani
 Any other Asian background
Black or Black British
 African
 Caribbean
 Any other Black background / Mixed
 White & Asian
 White & Black African
 White & Black Caribbean
 Any other mixed background / White
 British
 Irish
 Any other White background
Other Ethnic Group
 Chinese
 Any other ethnic group
 Prefer not to say
Please select the option which best describes your sexuality
 Lesbian
 Bisexual /  Heterosexual
 Prefer not to say /  Gay
Please indicate your religion or belief
 Atheism
 Buddhism
 Christianity
 Islam /  Jainism
 Sikhism
 Other /  Hinduism
 Judaism
 Prefer not to say
Do you consider yourself to have a disability or long-term health condition?
 Yes /  No /  Prefer not to say
If you have answered yes, which category describes your disability or condition
 Physical
 Learning Disability
 Other /  Hearing loss
 Mental health /  Sight loss  Prefer not to say
Have you ever identified as a transgender person? We use "transgender” as an inclusive umbrella term for a diverse range of people who find their gender identity or gender expression differs in some way from the gender they were originally assigned at birth.
 Yes /  No /  Prefer not to say
Caringresponsibilities – doyou look after, or give any help or support to family members, friends, neighbours or others?
 Yes /  No /  Prefer not to say

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