FURNACE HOUSE SURGERY

APPLICATION FORM

Please complete and return the form to:

Mr Phillip Davies, Practice Manager, Furnace House Surgery, St. Andrews Road, Carmarthen, SA31 1EX

Please complete in black ink or type

Application for the post of:

Closing date for receipt of Application:20th February 2017

  1. PERSONAL DETAILS:

Full name: ………………………………………………(Mr/Mrs/Miss/Other)

Home Address: ……………………………………………………………………..

..……………………………………………………………………

Postcode: …………………..Home Tel No: …………………………

Work Tel No: ……………………

Do you have a clean driving licence?YES / NO

(if not, please detail points and reasons)

Do you hold a current driving licence?YES / NO

Do you have the regular use of a car?YES / NO

Do you require a work permit?YES / NO

  1. PRESENT EMPLOYMENT

Name and address of present or most recent employer:

……………………………………………………………………………………………

……………………………………………………………………………………………

Current salary/wage: ......

GMC/NMC No. (If applicable)………………………….

Date appointed: ......

The period of notice you must give: ......

3.CURRENT POSITION AND BRIEF SUMMARY OF DUTIES

PLEASE ALSO STATE REASONS FOR LEAVING

  1. PREVIOUS EMPLOYMENT

Details of posts held over the last 10 years – most recent first / Post held / Number of hours worked / Period of employment
From To / Reasons for leaving
  1. GENERAL EDUCATION

Secondary schools/ further education / From / To / Qualifications and Grades

6.PROFESSIONAL EDUCATION

Professional Qualifications Obtained / Date

7.FURTHER STUDY

Qualifications currently being studies for / Level/part / Exam date / Method of study eg. college, correspondence

8.ADDITIONAL INFORMATION

You are invited in this section to give any additional information you feel is relevant to your application. This might include your hobbies and interests, your reasons for applying for the post, and why you think you should be appointed. (Please continue on a separate sheet if necessary).

9.REFERENCES

Please give the names and addresses of two people (relatives must not be used) who have agreed to act as a referee for you, one of whom must be your present or most recent employer. We will only contact your referees if you are invited for an interview, and you agree to attend.
Name:
Designation/Title:
Address:
Tel No: / Name:
Designation/Title:
Address:
Tel No:

10.REHABILITATION OF OFFENDERS

A)REHABILITATION OF OFFENDERS ACT 1974

Have you any criminal convictions which are not yet ‘spent’ under the Act?
YES / NO

B)EXEMPTION ORDER 1975

This post carries an exemption from the Rehabilitation of Offenders Act and you are therefore required to give details of all previous convictions.
Have you ever had any criminal convictions? YES / NO
You will be required to give full details of criminal convictions if you are short-listed for interview.

11. DECLARATION

I declare that the information contained in this form is true and complete. I understand that if it is subsequently discovered that any statement is false or misleading, the Practice has the right to dismiss me from my employment. I also understand that any offer of the post is subject to satisfactory medical examination, if required and satisfactory references.
Signature of applicant: …………………………………………
Date: …………………………………………