St George’s Hospital Charity - Application form: ref no: L755

Thank you for your interest. This application can be completed on your own PC, and returned by email to . The boxes will expand as you type or you may continue on a separate sheet.

The NHS Trust Development Authority is committed to ensuring that all appointments are made in a way that is open, transparent and fair to all applicants.All appointments are made on merit, in accordance with the Commissioner for Public Appointments' Code of Practice.

Your personal details

Surname
First name
Title
Honours
Home address
County
Postcode
Home contacts / Home Phone / Mobile
Email

Declaration of interests and ensuring public confidence

Do you have any business or personal interests that might be relevant to the work of the body for which you have applied and which could lead to a real or perceived conflict of interests were you to be appointed?

No / Yes

Should you be successful in your application, is there anything about your professional or personal history which, if brought into the public domain, may cause embarrassment or disrepute to the organisation. Have you received a prison sentence or suspended sentence of 3 months or more in the last 5 years?

No / Yes

If you answered yes to either question, please give details below. If you are invited to interview, this statement will be shared with the panel to allow them to explore this in the context of performing the role for which you are applying. Failures to disclose such information could result in an appointment being terminated.

Specific expertise

The person specification gives details of the particular skills and experience sought. Please read this information carefully before completing this section of your application. This is important, as the initial selection will be based on the extent to which you have demonstrated the expertise required. If you do not have any essential experience at the level required your application will not be considered further. The people who best demonstrate the essential experience required for the post will then be assessed against the desirable expertise and this will be used to differentiate between applicants otherwise of equal merit.

We are looking for candidates with the commitment, experience and networks to promote and support the vital work of St George's Hospital Charity as it embarks on its most ambitious fundraising appeal.
Essential: Please tell us about how you are able to contribute to the work of the Trustees, particularly using the skills and experience required for the post. This may include
·  Experience of operating at a senior strategic leadership level within an organisation
·  Successful track record of achievement through their career
·  Experience of charity governance and working with or as part of a Board of Trustees
·  Experience of external representation, delivering presentations and managing stakeholders
·  Significant experience of chairing meetings and events
·  Broad knowledge and understanding of the Civil Society sector and current issues affecting it
·  Strong leadership skills, ability to motivate staff and volunteers and bring people together
·  Financial management expertise and a broad understanding of charity finance issues
·  Good understanding of charity governance issues
Essential: Live in, work in or have strong links with South West London, the principal area served by St George’s University Hospitals NHS Foundation Trust.

Your CV

Please enclose a brief, up to date CV (no more than 2 sides of A4) outlining your employment history, any relevant voluntary work, public service or other experience, together with any relevant professional, academic or vocational qualification. Your CV will be used to assist the assessment of your expertise.


St George’s Hospital Charity - L755

Monitoring and other information

Monitoring information and analysis is used to establish who applies for our roles and enable action to be taken to ensure no group is treated unfairly and to improve the quality our services. Your answers will be treated confidentially and will not be shared with the selection panel unless explicitly stated.

Political Activity in the last 5 years

Please indicate all relevant activities undertaken in the last five years, together with the name of the related political party or body. If you have been or are an Independent or have sought or obtained office as a representative of a particular interest group, you should state this.

Obtained office as a Local Councillor, District Councillor MP, MEP, MLA etc.
Stood as a candidate for one of the above offices
Spoken on behalf of a party or candidate
Acted as a political agent
Held office such as Chair, Treasurer, or Secretary of a local branch of a party
Canvassed on behalf of a party or helped at elections
Undertaken any other political activity which you consider relevant
Made a recordable donation to a political party*
None of the activities above apply

Name of Party for which activity undertaken

Conservative / Liberal Democrats
Labour / Independent
Other / Please specify

Details of involvement - if you are invited to interview this statement will be shared with the panel to allow them to explore this activity in the context of performing the role for which you are applying.

* The Political parties, Elections and Referendums Act 2000 requires the Electoral Commission to publish a register of recordable donations (donations from any individual totalling £5000 in any calendar year, or more than £1000 if made to a subsidiary accounting unit such as a constituency association, local branch, women’s or youth organisation). These provisions became effective from 16 February 2001.

Date of birth

Gender

Male / Female

Ethnic Origin

White / Black / Asian/Asian British / Chinese / Mixed
British / African / Bangladeshi / Chinese / Asian & white
Irish / Caribbean / Indian / Black African & white
Any other white background / Any other black background / Pakistani
Black Caribbean & white
Any other Asian background
Any other mixed
Any other ethnic background - please give details: / / Background

Disability

Many people do not consider themselves to be disabled, but under the Disability Discrimination Act you can consider yourself disabled if you have a physical or mental impairment or long term health condition, and the effects are expected to last, or have lasted for a year or longer, and have a substantial effect on your ability to carry out day to day activities; or your day to day activities would be limited without medication, treatment or adjustments (for example the use of inhalers, physiotherapy, a hearing or visual aid or insulin). Taking this into account, do you consider yourself to be a disabled person?

No / Yes

Religion or beliefs

How would you describe your religion or beliefs?

Buddhist / Christian / Hindu / Jewish / Muslim
Sikh / Other / None/ Atheist

Sexual orientation

How would you describe your sexual orientation?

Bisexual / Gay man / Gay woman / Lesbian / Heterosexual

Your background

Profession (for regulated activities - please also provide your professional registration number):

Please indicate the sector in which you have spent the majority of your professional life:

Mostly private sector / Mostly civil service / Mostly wider public sector
Mostly third sector / Mixed

Ministerial appointments held

Have you ever held a ministerial appointment to any public body? Yes should only be selected if this would be your first regulated appointment to any public body, at any point in your life.

No / Yes

If yes, please give details of the organisation, the post and the dates concerned.

Declaration of interests and ensuring public confidence

Do you have any business or personal interests that might be relevant to the work of the body for which you have applied and which could lead to a real or perceived conflict of interests were you to be appointed?

No / Yes

The NHS TDA has a duty to ensure that those we appoint to NHS boards are of good character, will ensure an open and honest culture across all levels of the organisation and have not been associated with any serious misconduct or mismanagement relating to any office, or employment. Is there anything in either your professional or personal history which, may affect your eligibility for appointment or may cause embarrassment or bring the organisation into disrepute, were you to be appointed?

No / Yes

If you answered yes to either question, please give details below. If you are invited to interview, this statement will be shared with the panel to allow them to explore this in the context of performing the role for which you are applying. Failures to disclose such information could result in an appointment being terminated.

Please tell us how you found out about this post:

Thank you for taking the time to complete this form

Please return to or NHS TDA, Governance and Non-executive Development Team, 2C18, Quarry House, Leeds, LS2 7UE. Please contact us if you do not receive an acknowledgement.

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