Beccles Vasectomy Clinic

BECCLES MEDICAL CENTRE

Dr E K Bungay Dr G W Collins Dr T J Morton Dr P S Berry Dr R L Kathuria Dr I Nnene

Dr C Wiggins Dr E Picton Dr J McLean Dr M Hardman Dr C Hawkins Dr J Owen

St Mary’s Road Beccles Suffolk NR34 9NX

Tel (01502) 712662 Fax (01502) 712906

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APPLICATION FOR EMPLOYMENT

Please complete in your own handwriting. Even if you are submitting a CV as supplementary information, please also complete this application form in full to aid the shortlisting process.

TITLE OF POST APPLIED FOR …………………………………………………………...

Surname
First Name
Address
Home Telephone No
Mobile Telephone No
Work Telephone No
[if this may be used]
Email address
EDUCATION & TRAINING
Secondary Education / Dates – from and to / Qualifications & Grades
College / University / Dates – from and to / Qualifications & Grades
MEMBERSHIP OF PROFESSIONAL BODIES
Name of Body / Membership Status
PREVIOUS EMPLOYMENT – Please list all employment details during the last ten years - current / most recent first, use a separate sheet if required
Employer – Name & Address / Job Title & responsibilities / Dates – start and finish / Reason for leaving
STATEMENT IN SUPPORT OF YOUR APPLICATION
Please state why you are applying for this post and how your skills and experience match the requirements on the job description / person specification. Give examples of when you have used these skills – these need not all be from the workplace, but you may also have family or voluntary work experience which has given you transferable skills.
Continue on a separate sheet if necessary
REFERENCES
Please give the names of two people to whom we may apply for a reference. These should be employers and should not be friends or relatives. If you are unable to give the name of an employer because, for example, you are a school leaver or student, you should give details of a person in a responsible position at that institution who is able to comment upon your suitability. References from a voluntary agency or church will also be accepted if you have relevant volunteering experience and are unable to give the name of two employers.
References will not normally be sought until a job offer is made following a successful interview.
Reference One / Reference Two
Name / Name
Address / Address
Phone No / Phone No
HEALTH
Please note that a NO SMOKING policy is in force across all sites of Beccles Medical Centre
Please state the number of days you have had off sick during the past two years:
Number of Days …………………………. Number of Occasions …………………….
Any offer of employments will be subject to an Occupational Health Check.
INTERESTS
Please describe your leisure and social interests. If you have undertaken any voluntary work please state any positions of responsibility held.
ADDITIONAL INFORMATION
YES / NO
Do you hold a full current driving licence?
Do you have use of a motor vehicle?
Please provide details of any criminal convictions, excluding spent convictions under the provisions of the Rehabilitation of Offenders Act 1974.
All candidates who are offered a post at Beccles Medical Centre will be required to undergo a Criminal Records Bureau check before the offer is confirmed.

I confirm that to the best of my knowledge the above statements are true and I agree that if I have given false information or failed to supply relevant information, any subsequent offer of employment may be withdrawn or if already employed I may be dismissed.

Signed ………………………………………

Date …………………………………………