Application Form
(FOR USE IN COMBINATION WITH CV) /

Please complete in black pen to aid photocopying.

This form must be accompanied by copies of applicants CVs.

Position applied for:
How did you find out about the vacancy?
Name:
Address: / Title:
Post Code:
Contact details:
Email address:
Telephone number preferred for contact:
Alternative telephone number:

General Information:

Do you require a work permit to work in this country ?YES / NO

Do you hold a current work permit ?YES / NO / Not applicable

Criminal Records

All clinical roles in the hospice are exempt from the Rehabilitation of Offenders Act 1974 and require an Enhanced Check with the Disclosure and Barring Service. Certain other specified jobs require a Standard Disclosure. Applicants for these posts will be required to apply for a Disclosure Check prior to commencing in post. Otherwise, the provisions of the Rehabilitation of Offenders Act 1974 apply.

Do you have any unspent criminal convictions?YES / NO

If shortlisted for interview, please give any days/ dates when you would NOT be available:

RECRUITMENT MONITORING FORM

St Peter’s Hospice is working to ensure that our workforce of staff and volunteers reflects Bristol’s diverse population. We can only judge our success in this area if we obtain and track information regarding the gender, ethnicity and disability of people who apply to work with us and we would appreciate your co-operation by completing the details below.

The information will be kept confidential and used for monitoring purposes.

NAME: ……………………………………POST APPLIED FOR: …………………………………………

1. Gender:

Male  Female 

2. Disability:

St Peter’s Hospice uses the following definition of a Disability: “a physical or mental impairment which has a substantial and long-term adverse affect on a person’s ability to carry out normal day to day activities”.

Do you consider yourself to be a Disabled person?YES / NO

If so, are you registered disabled?YES / NO

3. Ethnic Origin:

How would you describe your ethnic origin? Please tick one box.

(Please note that these categories reflect those used in the 2001 Census)

Asian or Asian British:Black or Black British:Chinese:

Indian Caribbean Chinese 

Bangladeshi African 

Pakistani Any other Black background 

Any other Asian background 

Mixed:White: Other Ethnic Group:

White and Black Caribbean British  Other

White and Black African  Irish 

White and Asian Any other White background 

Any other mixed background 

The collection of equalities information conforms to employment provisions in the Sex Discrimination Act (1975), the Race Relations Act (1976) and the Disability Discrimination Act (1995).

Application Form with CV