Application Form

This is the first stage in the selection procedure where Headway Cardiff will identify suitable applicants to attend

interview.This part of the assessment is based on the information which you provide below. It is important, therefore, that you include as much information as possible about yourself and what you have done. Some of the information asked is required to complete a DBS check, so it is vital that the information you provide is accurate. You will be asked to bring original copies of Identification documents to support your application, should you be successful at application stage.

Please complete each section below in black ink as this form may be photocopied.

Please ensure that all parts of the application form are completed in full and returned to the Chief Executive at Rookwood Hospital or via email to

Please be aware you will be notified if your application has been successful and invited to attend an interview. It is with regret that due to the volume of applications we receive, you will not be notified if you have been unsuccessful.

Title of post applied for: / Closing Date:
1. PERSONAL DETAILS (BLOCK CAPITALS PLEASE)
Surname: / Forenames:
Former Forename or Surnames if different: (Please provide dates if applicable: Continue on reverse of application if necessary) / Forename/ Surname
Changed:
From: on / /
To: until / / Preferred title (Dr, Mr, Mrs, Ms, Miss etc):
Address: / Tel No (home):
Tel No (business):
Tel No (mobile):
Post Code:
Date moved in: <dd/mm/yyyy> / Preferred Contact:
Have you lived at this address for 5 years or more: / Yes
No / If no, you will be required to provide all addresses for the last 5 years including postcode and dates of occupation on the continuation page at the end of this application form:
E-Mail address: / Nat. Insurance No:
DBS Reference number
Do you need a work permit to be employed in the UK? / Yes
No / If you already have a work permit, when does it expire?
How did you hear about the post?
2. EDUCATION AND PROFESSIONAL QUALIFICATIONS
Please detail in chronological order, with most recent first. Please continue on a separate page if necessary.
(Include professional qualifications, apprenticeships or government-sponsored schemes, as appropriate.
Indicate whether full-time, part-time or home study). Original documents as proof of qualification may be required
at interview. If you are currently studying, please indicate what stage you are in regards to completion.
Secondary School / College / University/ / Dates / Examinations taken / Date / Result
From / To
Professional Qualifications and/ or membership currently held: Grade and date
Other relevant Educational or Training Courses, with dates (including Health and Safety related- i.e. Manual Handling or First Aid)
3. PRESENT POST
Title of Post: / Salary/Grade:
Name of Employer: / Business of Employer:
Address: / Date Commenced:
Date Ended (if applicable):
Town. / Post Code.
Please outline your responsibilities, to whom you are responsible and staff responsible to you (if applicable):
Reason for leaving or wishing to leave:
Period of notice required to terminate present employment:
Please notify us of any dates you are not available for interview and any interview considerations/ alterations you may need:
4. PREVIOUS EMPLOYMENT
Name and Address of Employers / Position held / Dates / Reason fo
leaving / Final grade/salar
From / To
Description of duties:
Description of duties:
Description of duties:
5. PLEASE OUTLINE HOW YOU FEEL YOU MATCH THE PERSON SPECIFICATION OF THE JOB PROVIDING SPECIFIC EXAMPLES AND EVIDENCE. (Continue on a separate sheet if necessary).
6. OTHER INFORMATION
Do you hold a current driving license? / Yes No / Do you own a car? / Yes No / Would you be prepared to use your own vehicle for business use? (Where relevant) / Yes No / Do you currently have insurance for business use?
(Where relevant) / Yes No
You would be required to provide copies of your current MOT Certificate and Insurance confirming business use, before commencing employment. (Where relevant)
Statement / Yes / No
Any Criminal Convictions in the last 5 years (i.e. Unspent convictions)
Any Criminal Convictions greater than 5 years (Spent)
Any unexplained gaps in employment in the last 5 years
Any Penalty points on your license, or any pending
Any disqualification for driving in the last 5 years
If answered yes to any of the above, please give details.
(You are reminded that failing to disclose information requested as above or falsification of information may lead to dismissal from the company on the grounds of gross misconduct.)
If offered a job with Headway Cardiff, you may be required to obtain and submit to the Company a certificate from the Disclosure Barring Service, giving details of any convictions.
7. REFERENCES- Please provide details for your present and most recent employers, not character references. You must provide the full names, addresses and postcodes.

Referee 1

/

Referee 2

Title (Mr, Mrs etc): / Title (Mr, Mrs etc):
Full Name: / Full Name:
Job Title: / Job Title:
Organisation: / Organisation:
Address: / Address:
Town. / Post Code. / Town. / Post Code.
Tel No: / Tel No:
E-mail address: / E-mail address:
Fax No: / Fax No:
Please state if we may obtain this reference prior to interview. / Yes No / Please state if we may obtain this reference prior to interview. / Yes
No

8. DECLARATION

Data Protection Act 1998

Any data about you will be held in secure conditions with access restrictions. Data will also be used for employment monitoring purposes however all data will be kept anonymous. If you are unsuccessful, your application will be destroyed after 3 months. If you are the successful candidate, relevant information will be taken from this form and used as part of your personal record.

Rehabilitation of Offenders Act 1974

Under the Rehabilitation of Offenders Act 1974 criminal convictions can become spent or ignored after a rehabilitation period, although they remain on the Police National Computer. The rehabilitation period varies depending on the sentence or order imposed by the court - not the offence. Custodial sentences of more than two and half years can never become spent. Headway Cardiff is exempt from the Act due to the nature of our work and the vulnerable people we work with, therefore all convictions, spent or unspent must be declared.

Asylum and Immigration Act 1996 (Section 8)

This act makes it a criminal offence for an employer to take on new staff whose immigration status prevents them from taking up the post in question. This applies to all types of employment, including part-time, temporary or casual appointments. For most jobs you will only be asked to produce one or two documents if you are offered the job. Documents will be checked as a completely separate process.

I declare that the information contained in this application is complete and correct. I understand that, if I have knowingly provided false information in my application, I may be disqualified or dismissed after appointment.

I consent to the use of this information as outlined above.

Signature: ______Date: ______

Continuation Page.

Change of Address Record:
Address:
Postcode: / Date moved in: dd/mm/yyy / Date moved out dd/mm/yyyy
Address:
Postcode: / Date moved in: dd/mm/yyyy / Date moved out dd/mm/yyyy
Address:
Postcode: / Date moved in: dd/mm/yyyy / Date moved out dd/mm/yyyy
Address:
Postcode: / Date moved in: dd/mm/yyyy / Date moved out dd/mm/yyyy
Address:
Postcode: / Date moved in: dd/mm/yyyy / Date moved out dd/mm/yyyy
Change of Name Record:
Forename/
Surname / Changed from- dd/mm/yyyy / Changed until- dd/mm/yyyy
Forename/
Surname / Changed from- dd/mm/yyyy / Changed from- dd/mm/yyyy

Application Form