Associates & Partners Application Form

ASSOCIATES & PARTNERS APPLICATION FORM

Your completed application form and diversity monitoring form (attached below) should be emailed, preferably as a Word document, to associates&

We prefer to receive applications electronically, but if you need to send in a paper application please do so to:

Thank you for completing this form. Please do not attach a CV – import the relevant information from the CV into the appropriate sections of this form

We will anonymise this form for long and shortlisting. Please make it easier for us to do so by not including your name, or anything else that could indicate your gender or ethnicity, in the body of the application other than on this first page.

Please complete legibly in black or blue ink or type

Application for position of: / Chair of the Board of Assessors
Your name
Include title, forenames and surname.
Address (include postcode) / Telephone (Home)
Email address / Telephone (Work)
(Leave blank if you do not wish it used)
Nationality / Telephone (Mobile)
Are there any restrictions on your continued residence or employment in the UK?
YES/NO (If ‘Yes’, specify below.) / Are you required to hold a work permit in order to work in the UK? YES/NO (If ‘Yes’, specify below.)
Are you related to any member of the GPhC’s Council or to any employee of the GPhC? YES/NO (If ‘Yes’, specify below.) / How did you find out about this post? (Please specify below.)
Colleague Relative / friend
Professional journal
Newspaper advertisement (please specify)
Other (please specify)
EDUCATION AND PROFESSIONAL QUALIFICATIONS
Education, professional qualifications (including entries in the register of the GPhC or any other regulatory bodies and membership of professional bodies).
Please include your GPhC pharmacist registration number.
Schools/Colleges/Universities etc / Dates (from – to) / Examinations passed (including grades), qualifications obtained
Training and Short Courses
Please detail any recent training you have undertaken relevant to this post.
CURRENT EMPLOYMENT & EMPLOYMENT HISTORY, INCLUDING VOLUNTARY WORK
Please give details of all full-time and part-time work within the last 10 years. Include paid and unpaid employment, key positions in the voluntary sector, positions held while a student, and membership of central or local committees. Please indicate experience of either chairing or membership of boards, committees, groups and/or current or past public appointments.
Dates (From - To) / Position / organisation / main responsibilities
SKILLS, KNOWLEDGE AND EXPERIENCE
This section is designed to let you tell us something about
· yourself
· your experiences
· your skills; and
· your abilities
and how you think they meet our essential and desirable criteria.
Please be sure to include at least one example of your experience or achievements to date which best illustrates each of the essential and (where possible) desirable criteria on the role description.
Remember:
¨ The achievements might have resulted through things you have done in any kind of setting – for example, paid employment or voluntary work, at school or college, in connection with your hobbies or interests etc
¨ The information provided will form part of the shortlisting and interview process
¨ We are asking you to complete this questionnaire so that your accomplishments and abilities, which are relevant to the role, are taken into account in your application
¨ Please try and provide recent examples and avoid using the same example more than once.
Continue on a separate sheet if necessary but please put your full name on any additional sheets
SKILLS, KNOWLEDGE AND EXPERIENCE continued
Continue on a separate sheet if necessary but please put your full name on any additional sheets
DECLARATION
Do you have any convictions that are unspent under the Rehabilitation of Offenders Act 1974? /

Yes

No

Have you any prosecutions pending? /

Yes

No

If yes, please give details / dates of offence(s) and sentence:
Are you currently subject to any fitness to practise, disciplinary or similar proceedings or a party in any other circumstances which could bring the GPhC into disrepute? /

Yes

No

If yes, please give details below:
We value diversity and wish to promote it on our Council and Committees. Should you require any reasonable adjustments at any stage of the process or in post then please let us know. You can give details below if you wish.
I confirm that to the best of my knowledge and belief, the information given in this form is complete and correct.
I understand that if I am appointed and the information I have provided is subsequently found to be untrue then my tenure of office may be terminated.
Signature / Date

We will use your personal information in line with the Data Protection Act 1998. We will share some of the information you give with the members of the selection panel so that your application can be assessed. Information will be kept by the GPhC for up to two years after the closing date for applications. If at any time you want your personal information to be removed from GPhC records, please contact associates&. We may keep information about candidates who are unsuccessful this time so that we can tell them about any opportunities they might be interested in during the next twelve months. Please tell us if you do not want us to do this.

GPhC Chair of the Board of Assessors – Application form 2

GPhC Equalities Monitoring Form

Equalities Monitoring Form

The GPhC values equality and diversity and is committed to making sure its processes and procedures are fair, transparent and free from unlawful discrimination. To make sure we are treating candidates fairly, we monitor diversity at all stages of the appointments process. You don’t have to give us this information, but we would be grateful for your cooperation. Information you give on this form will be treated as strictly confidential and will only be used for monitoring. It will not be seen by anyone directly involved in the selection process, and will not be treated as part of your application. No information will be published or used in any way which allows anyone to be identified.
Application for the post of:
Gender / Male / Female / Other
Sexual orientation / Heterosexual / Lesbian / gay / Bisexual / Other
Disability
Disability is defined as “physical or mental impairment, which has a substantial and long term adverse effect on a person’s ability to carry out normal day to day activities”.
Do you consider yourself disabled? / Yes / No
If yes, please give details:
Age Group
Under 20 years / 20 - 29 years / 30 - 39 years
40 - 49 years / 50 - 59 years / 60+ years
What is your ethnic group?
Choose the appropriate box to indicate your cultural background.
White / Black or Black British
British / Black Caribbean
Irish / Black African
Other white background (please give details below) / Any other black background (please give details below)
Mixed / Asian or Asian British
White & black Caribbean / Indian
White & black African / Pakistani
White & Asian / Bangladeshi
Other mixed background (please give details in box below) / Any other Asian background(please give details in box below)
Chinese or Chinese British / Other ethnic background
Chinese /Chinese British / Other ethnic background
Please give more information here:
Media
How did you find out about this post?
Date completed

Your completed application form and diversity monitoring form (attached below) should be emailed to associates&

We prefer to receive applications electronically, but if you need to send in a paper application please do so to:

Thank you for completing this form.

Recruitment Monitoring Form 9