Confidential application

for employment

If posting this application, please send to:

Caroline Tyler, HR Advisor, HR Department

Acorns Children’s Hospice, Drakes Court, Alcester Road, Wythall, B47 6JR

Tel: 01564 825033, alternatively, email your application to

Position applied for:

Personal details

Title: (Please specify) *Mr * Mrs * Miss * Ms * Other:
Last name:
First names(s):
Address:
Post Code:
Telephone number: Private:
Business: Mobile:
Contact email address:
NI number:
Do you hold a current driving licence? * Yes * No
Do you have the use of a motor car? * Yes * No
Do you need a work permit for employment in the UK? * Yes * No
Please list any foreign languages spoken or written, indicating degree of fluency:
If offered this position, will you continue to work in any other capacity? (Give details):
Do you have any personal relationship or family connection with any of the children or young people who currently use Acorns services or have done in the past? If so, please give brief details.
Membership of Professional Bodies (include NMC registration where applicable):
Name: Renewal/ expiry date:
Membership/status: Number:
Name: Renewal/ expiry date:
Membership/status: Number:

Career history

Previous employment: Please include any previous experience (paid or unpaid), starting with the most recent first. Include a note of all periods of unemployment; travel etc. in the space provided so there are no gaps in the record.

*Please specify separately under salary the cash values of any bonuses/allowances or benefits.

Current or most recent employer

Name of Employer:
Address:
Post Code:
Position held:
Date started: Date of leaving:
Reason for leaving:
*Salary on leaving: Notice period:
Brief description of duties:

Previous employer

Name of Employer:
Address:
Post Code:
Position held:
Date started: Date of leaving:
Reason for leaving:
*Salary on leaving: Notice period:
Brief description of duties:

Previous employer

Name of Employer:
Address:
Post Code:
Position held:
Date started: Date of leaving:
Reason for leaving:
*Salary on leaving: Notice period:
Brief description of duties:

Previous employer

Name of Employer:
Address:
Post Code:
Position held:
Date started: Date of leaving:
Reason for leaving:
*Salary on leaving: Notice period:
Brief description of duties:

Gaps in your employment

Please provide information of any gaps in employment.

From (month/year) / To (month/year) / Reason

References

Please give the name, address and position of two referees we may contact (not relatives, personal friends or employees of Acorns). At least one of these should be from your last employer.

Name:
Job title:
Organisation:
Address (in full):
Telephone no:
Email: / Name:
Job title:
Organisation:
Address (in full):
Telephone no:
Email:
May we approach your present employer for a reference prior to any conditional offer of employment
* Yes * No
Criminal Convictions
Because of the nature of the work for which you are applying, the post is exempt from the Rehabilitation of Offenders legislation. You must still declare any cautions, convictions or reprimands and tell us if there are any proceedings outstanding against you. In the event of employment failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relevance to an application for positions to which the Rehabilitation Offenders Act 1974 (Exceptions) Order 1975 applies.
Details of declaration of criminal record:
Acorns Children’s Hospice Trust use the Disclosure and Barring Service to help assess an applicant’s suitability for work involving contact with children and young people. An Enhanced Disclosure (police check) will be requested in the event of a successful application in line with Acorn’s Disclosure Policy.

Additional information

Please give your reasons for applying for this post and tell us how your experience, skills and qualifications meet the requirements of the post. Please supply any additional information which you may feel might support your application. You may draw on experiences from your personal life such as voluntary work or work in the home.

You may provide additional continuation sheet/s, which clearly states your name and the position you are applying for.

Education, training and qualifications

School
Schools attended from age 11 / Examination
(Subjects/results)
Further education
Place of education / Type of training / Qualifications
Special courses / other qualifications / Examination results and dates


Declaration

I declare that all information given by me in this document is correct and will form part of my contract of employment should I be offered a post with Acorns Children’s Hospice Trust or any associated company. I agree to the organisation verifying the information given. Any false statement may be sufficient cause for rejection or, if employed, dismissal without notice. I also confirm that I am not disqualified from working with children and understand that a Child and Adult Workforce Enhanced Disclosure will be sought in the event of a successful application for posts in line with Acorn’s Disclosure Policy.

I understand and agree that data contained in the application form will be used and processed for recruitment purposes. I understand and agree that should I become an employee, the information will also be used for employment related purposes and I agree to Acorns Children’s Hospice Trust holding and processing this information in line with the Data Protection Act.

Signed: ……………………………………………………………………… Date: …………………………….

Please tick this box if applying electronically

* I confirm that all the information provided in this application is accurate and correct and has been completed by myself. I acknowledge that I have read and agree with the above declaration.

Equality Monitoring Form

Acorns is committed to equal opportunities in our recruitment process, in order to find out how well we are doing with this we need to collect monitoring data from the nine protected characteristic groups – protected under the Equality Act 2010.

This information WILL NOT be taken into account in selection. It will be separated on receipt and treated as confidential. We would be grateful if you could take a little time to complete this optional form.

Date of Birth:

Are you married or in a civil partnership?

Yes ¨ No ¨ Prefer not to say ¨ If other, please write in:

What is your religion or belief?

No Religion or belief ¨ Buddhist ¨ Christian ¨ Hindu ¨

Jewish ¨ Muslim ¨ Sikh ¨ Prefer not to say ¨

If other religion or belief, please write in

What is your ethnicity?

Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong to.

White

English ¨ Welsh ¨ Scottish ¨ Northern Irish ¨ Irish ¨

British ¨ Gypsy or Irish Traveller ¨ Prefer not to say ¨

Any other white background, please write in:

Mixed/multiple ethnic groups

White & Black Caribbean ¨ White & Black African ¨ White & Asian ¨

Prefer not to say ¨ Any other mixed background, please write in:

Asian/Asian British

Indian ¨ Pakistani ¨ Bangladeshi ¨ Chinese ¨

Prefer not to say ¨ Any other Asian background, please write in:

Black/African/Caribbean/Black British

African ¨ Caribbean ¨ Prefer not to say ¨

Any other Black/African/Caribbean background, please write in:

Other Ethnic group

Arab ¨ Prefer not to say ¨

Any other ethnic group, please write in:

What is your gender?

Male ¨ Female ¨ Prefer not to say ¨

Have you ever identified as transgender?

Yes ¨ No ¨ Prefer not to say ¨


What is your sexual orientation?

Heterosexual ¨ Gay woman/lesbian ¨ Gay man ¨ Bisexual ¨

Prefer not to say ¨ If other, please write in:

Do you consider yourself to have a disability or health condition?

Yes ¨ No ¨ Prefer not to say ¨

What is the effect or impact of your disability or health condition on your ability to give your best at work? Please write in:

The information in this form is for monitoring purposes only. If you believe you need a ‘reasonable adjustment’, then please discuss this with your manager, or the manager running the recruitment process if you are a job applicant.

How did you find out about this position?

Acorns Website Yes ¨ No ¨

Word of mouth Yes ¨ No ¨

Online Publication/Jobs Board, please write in:

Printed Publication, please write in:

Recruitment Agency, please write in:

Other, please write in:

This information will be held and processed by Acorns Childrens Hospice Trust in line with the Data Protection Act 1998.

Thank you for completing this form