Application Form – Disclosure & Barring Service Associated Roles

Post applied for:
Post reference no: / Date of application:
How did you hear about this post: /
  • Thames hospice website
  • Other website , please specify
  • Local press, please specify
  • Other, please specify

PERSONAL INFORMATION
Surname: / First name(s):
Title: / Mr Mrs Miss Ms Dr
Other, please specify
National Insurance Number:
Address:
Mobile telephone: / Home telephone:
Email address:
Are you legally eligible to work in the UK? / Yes No / Do you have proof of eligibility to work in the UK, e.g, a British Passport? / Yes No
Do you hold a full, current EU driving licence?
(The job description states if this is a requirement.) / Yes No
Not applicable for this role
Do you have access to a vehicle which can be used for work purposes?
(The job description states if this is a requirement.) / Yes No
Not applicable for this role
Are you related to a current employee of Thames Hospice?
If yes, please state name of employee and your relationship with them: / Yes No
Employee Name:
Relationship:
CONVICTIONS
If you are applying to work directly with Thames Hospice patients, or in a role which meets the definition of regulated activity prior to September 2012 you will be required to complete an enhanced Disclosure & Barring Service check in which you will be asked to disclose any criminal offences for which you have been convicted, whether spent or unspent. This post is one covered by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975.
The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are ‘protected’ and are not subject to disclosure to employers, and cannot be taken into account. Guidance and criteria on the filtering of these cautions and convictions can be found at the Disclosure and Barring Service website. Do you have any convictions, cautions, reprimands, final warnings or cases pending against you that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198?
Yes No
If yes, please specify:
Are you currently named on the Adults Barred List?
Yes No
If yes, please specify on a separate sheet and enclose in an envelope marked CONFIDENTIAL
Are you registered with the DBS Update service? Yes No
If yes, and your application for this postition is successful, do you consent to Thames Hospice using the update service to check your DBS status? Yes No
EMPLOYMENT HISTORY
Please give full details of all previous employment, explaining any gaps. Please start with the most recent.
Current or most recent employer:
Address:
Dates or employment (month and year): / From: To:
Position(s) held:
Current salary and reason for leaving:
Notice required in current post:
Please give a brief description of your responsibilities and duties
Dates of employment
(From and to) / Name & address of employer / Job title & duties / Reason for leaving

Please continue on a separate sheet if necessary.

EDUCATION AND PROFESSIONAL QUALIFICATIONS
Subject / qualification / Place of study / Grade / result / Year obtained

Please continue on a separate sheet if necessary.

DETAIL MEMBERSHIP OF PROFESSIONAL BODIES
Please include the name of the organisation, personal membership number and date of its expiry.
e.g NMC, GMC etc
SUPPORTING STATEMENT
Please explain below how you meet the requirements of the person specification. This is most easily done by taking each point in turn.
You may wish to include skills developed away from the workplace which you believe would be beneficial in this role.

Please continue on a separate sheet if necessary.

REFEREES
Please provide details of two referees who are not related to you – both must be previous employers, including the most recent. Please include the most recent employment you had in connection with children or adults in a regulated setting.For an employer referee, please provide full company contact details to include a professional e-mail address.
If you have not been employed previously or have only had one job, please nominate an academic referee, someone of standing in the community who knows you e.g. Doctor, Solicitor or a referee from any voluntary work you have undertaken. The referees must not beprevious colleagues or current employees of Thames Hospice.
REFEREE 1
Name:
Occupation:
Company:
Full address:
Email address:
Contact telephone no:
What is your connection with this referee? / How long have you known this referee?
REFEREE 2
Name:
Occupation:
Company:
Full address:
Email address:
Contact telephone no:
What is your connection with this referee? / How long have you known this referee?

Please tick if you do not wish your current employer to be approached for a reference prior to any offer of employment.

Declaration

In making this application to Thames Hospice:

  • I confirm all information contained within this form and any related document is complete and accurate in every respect. I accept Thames Hospice is entitled to withdraw any offer of employment, or terminate my employment, with immediate effect if the information contained in my application is found to be inaccurate or untrue.
  • I confirm my information may be held by Thames Hospice in accordance with the Data Protection Act 1998.
  • I understand references will only be collected by Thames Hospice if I am offered and accept employment.
  • I understand that any offer of employment will be subject to evidence of entitlement to work in the UK, receipt by Thames Hospice of two satisfactory references, medical health check and satisfactory completion of a Disclosure and Barring Service check (where applicable to role) and evidence of a full, current UK/EU driving licence (where applicable to role).
  • I understand and accept that Thames Hospice is a no-smoking organisation.
  • I understand that my email will be taken as my agreement to this declaration if I submit my application electronically.

Applicant’s signature: ______

Applicant’s name: ______

Date: ______

Equal Opportunities

In accordance with its policy on equal opportunities in employment, Thames Hospice will provide equal opportunities to any employee or job applicant and will not discriminate either directly or indirectly because of race, sex, sexual orientation, gender reassignment, religion or belief, marital or civil partnership status, age, disability, or pregnancy and maternity.

In order to assess how successful this policy is we have set up a system of monitoring all job applications. We would therefore be grateful if you would complete the questions on this form. We have asked for your name to enable us to monitor applications at short-listing and appointment as well as application stage.

All information will be treated in confidence and will not be seen by staff directly involved in the appointment. The questionnaire will be detached from your application form, stored separately and used only to provide statistics for monitoring purposes. Thank you for your assistance.

1. / Post title:
2. / Full name:
3. / Gender: / Male Female
4. / Was this the gender you were assigned at birth? / Yes No
5. / Date of birth:
6. / Marital status: / Married Single
Divorced Widowed
7. / Do you have any responsibility for dependants? (Dependants relates to children, or elderly or other persons for whom you are the main carer.) / Yes No
8. / Do you have any disabilities?
Do you require any assistance with the interview process? / Yes No
Yes No
9. / Ethnic origin:
I would describe myself as (choose ONE section from A to E, and then tick the appropriate box to indicate your cultural background)
A. / White:
British Irish
Any other white background, please specify
B. / Mixed:
White and black Caribbean White and black African White and Asian
Any other mixed background, please specify
C. / Asian or Asian British:
Indian Pakistani Bangladeshi
Other Asian, please specify
D. / Black or Black British:
Caribbean African
Any other black background, please specify
E. / Chinese or other ethnic group
Chinese Any other, please specify:

Data Protection: Information from this application may be processed for purposes registered by Thames Hospice under the Data Protection Act 1998. Individuals have, on written request, the right of access to personal data held about them.

I hereby give my consent to Thames Hospice processing the data supplied in this form for the purpose of recruitment and selection. I understand that my e-mail will be taken as my consent if I submit my application electronically.

Applicant’s signature: ______

Applicant’s name:______

Date: ______

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