Charity No: 1003314

Registered in England No: 2620879

APPLICATION FOR EMPLOYMENT

We are committed to equal opportunities in employment and service delivery and are only interested in your ability to do the job.

Please complete in clearly written or typed black ink, continuing on separate sheets if necessary
POSITION APPLIED FOR:
POST REFERENCE (If quoted):
WHERE DID YOU SEE THIS POST ADVERTISED:
(Please specify publication and date)
1. PERSONAL DETAILS
Title: / Surname: / Forenames:
Address: / Tel (daytime):
Tel (evening):
Tel (mobile):
Email address:
Postcode: / N.I. number:
2. EMPLOYMENT HISTORY
a) Present or most recent employment
Employer’s name and address:
Position held: / Salary:
Dates from / to:
Period of notice / date available to start:

Principal responsibilities and duties of current position:
Reason for seeking new position / leaving:
b) Employment History
Please start with the most recent including any unpaid or voluntary work.
Continue on a separate sheet if necessary
Employer / Dates from – to
(month/year) / Position held / Reason for leaving / Salary
Please give details and an explanation of any gaps in your employment history:
3.EDUCATION, TRAINING AND DEVELOPMENT
a) Secondary school/college/university/apprenticeship including current studies with the most recent first. Continue on a separate sheet if necessary
Name ofinstitution / Full orpart-time / Courses/subjects taken / Dates from –to(month/year) / Qualifications/grade and year obtained
N.B We reserve the right to contact employers or educational establishments to verify details given.
b) Details of any relevant learning and development
(e.g. short courses, first aid, computer skills, work-based NVQ including any current ones)
Course / skill / Date from – to (month/year)
c) Professional membership/qualification
Name of professional body / Grade of membership/qualification/status/ professional registration or pin number / Date/expiry date
4. SUPPORTING STATEMENT
Please read the job description and the person specification. Using examples, show how your knowledge,
skills and experience meet each of the essential requirements of the person specification and as many
desirable requirements as possible. Please incorporate all relevant experiences including paid employment,
voluntary work, and other activities including what you feel you could contribute to Children’s Hospice
SouthWest. Please continue on a separate sheet as necessary.
Supporting Statement (Cont)…….
5. ADDITIONAL INFORMATION
Please write below any other information you may care to provide such as interests, hobbies,specialised knowledge, languages etc. not included previously:
Please circle YES or NO for each of the following questions:
Are you eligible to work in the UK? / YES NO
Do you require a work permit? / YES NO
Do you hold a full driving licence? / YES NO
Are you related to a Director or Employee of Children’s Hospice South West? / YES NO
If yes please give details:
Please declare any work or activities that you are undertaking which could potentially result in a conflict of interest or impact on the reputation of Children’s Hospice South West:
6. REFERENCES
We will seek references covering the last 5 years of your employment (where appropriate). Please give details of two referees, one of whom should be your most recent employer. For posts that involve working directly with children one reference must relate to a period where you were working in contact with children. If you are in or havejust completed full-time education, one referee should be from your school, college or university. Refereesmust not be related to you and must be able to comment on your skills and abilities in relation to the post.References may be taken up before an interview or offer of employment, unless your request otherwise.
Reference 1 / Reference 2
Name: / Name:
Address: / Address:
Tel No: / Tel No:
Email: / Email:
Capacity known to you: / Capacity known to you:
How long have they known you? / How long have they known you?
I agree to this reference being taken up before an interview or offer of employment being made
YES NO / I agree to this reference being taken up before an interview or offer of employment being made
YES NO
7. OTHER

Criminal Convictions
Under the Health and Social Care Act 2008, all employees of Children’s Hospice South West must apply for a disclosure from the Disclosure and Barring Service, as the post is exempt from Section 4(2) of the provisions of the Rehabilitation of Offenders Act 1974. Applicants are, therefore, not entitled to withhold information about convictions which for other purposes are not ‘protected’ (i.e. filtered out) as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013. For further information, please refer to DBS filtering guidance at If you have a conviction, that is not ‘protected’, it MUST BE DISCLOSED. Any offer of appointment made following this application is made subject to a successful Enhanced DBS disclosure. If you fail to make a full disclosure then your application will not be confirmed. In the event of employment, failure to disclose previous convictions or pending court cases could result in dismissal or disciplinary action. Any information will be treated in the strictest confidence. Having a criminal record does not necessarily bar you from working with us. This will depend on the nature of the position and the nature of the circumstances and background of the offence/s.
Do you have any convictions, cautions, reprimands or final warnings which are not ‘protected’ as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013? YES / NO (please delete as appropriate)
If YES please give details below including date, court and nature of offence:
……………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………
Have you been/or are you the subject of fitness to practice proceedings by any professional registration bodies? YES NO
Have you had any Count Court Judgement (CCJs) or Bankruptcy proceedings? YES NO
If yes, please provide further details below:
The information given in this application may be verified for fraud prevention purposes. Alternative evidence may also be sought for verification purposes.
In connection with your application, CHSW may be subject to background checks. Depending on the nature of the position that you are applying for these checks may include criminal record, qualification, medical, credit, right to work as well as other verification checks that we may feel are appropriate.
8. YOUR SIGNATURE (online applicants please tick the box below)
I certify that to the best of my knowledge the details provided on this form and all other supporting papers are true and correct. I understand that if I have provided false or misleading information in response to any questions on this form or have failed to disclose information, this will result in the termination of any contract of employment entered into, or withdrawal of any offer of employment. Furthermore, I understand that canvassing or failure to disclose a relationship to a member or senior officer will disqualify my application. I give my explicit consent to the processing of data contained or referred to on this form, in accordance with the Data Protection Act 1998 and any subsequent legislation. I also understand that appointment may be subject to a satisfactory medical examination.
………………………………………………………………………………………… ………………………………………………
Signature of Applicant Date

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Equal Opportunity Monitoring Form
Section 1 About the job applied for
Date
Organisation
Job Title
Section 2 Gender (Please indicate below)
FEMALE / MALE/ TRANSGENDER
Section 3 Age range (Please indicate in the box provided)
16-25 years / 26-35 years / 36-45 years / 46-55 years / Over 55 years
Section 4 Ethnicity (Please Indicate in the box provided)
A. Asian or Asian British
Indian / Pakistani / Bangladeshi / Any other Asian background,
Please write below
B. Black or Black British
Caribbean / African / Any other black background please write below
C. Chinese, Chinese British or any other ethnic group
Chinese / Chinese British / Any other background, please write below
D. Mixed
White and Black Caribbean / White and Black African / White and Asian / Any other mixed Background, Please write below
Equal Opportunity Monitoring Form (Continued)
E. White
English / Scottish / Welsh / Irish / Any Other White Background, Please Write Below
Section 5 Disability (Please see guidance below)
Do you consider yourself to have a disability? / YES / NO
Section 6 Where did you first see this post advertised?
Local Newspaper / National / Trade Press / Other (Please State)

GUIDANCE NOTES ON DISABILITY

Under the disability Discrimination Act 1995 you are considered to have a disability if you have ‘a physical or mental impairment which has substantial and long-term adverse affect upon your ability to carry out normal day-to-day activities’.

People who have had disabilities in the last year are included. Progressive conditions, such as cancer, multiple sclerosis, muscular dystrophy and HIV infection, are covered by the Act from the moment the condition leads to an impairment, which has some effect on the ability to carry out normal day-to-day activities.

DECLARATION

The information you have given on this form is entirely confidential and will be kept for monitoring purposes only.

The information is kept separately from your application form and is not divulged to any third party.

The information is stored in accordance with our responsibilities under the Data Protection Act.