DR KERSHAW’S HOSPICE

CONFIDENTIAL

DR KERSHAWS HOSPICE

APPLICATION FOR EMPLOYMENT

Please complete this form in black ink or typescript, for photocopying purposes. This form must be completed in

detail in order for your application to be considered. Curriculum Vitae may be enclosed as a supplement to the

information given on this form but not as a substitute for it.

Continue any section on a separate sheet if necessary, quoting your name and post reference number

1. PERSONAL INFORMATION
Surname: ……………………………………………………… Preferred title: ………………………………………………….
Forenames: ……………………………………………………
Address: ……………………………………………………… Home telephone no: ……………………………………………
………………………………………………………………… Work telephone no: …………………………………………….
Post Code: ……………………………………………………. Mobile telephone no: …………………………………………..
Do you hold a current EC Passport? YES/NO Do you require a work permit to undertake this post? YES/NO
If offered employment, when would you be Do you hold a current driving licence? YES/NO
available to start work?
Are you presently a vehicle owner? YES/NO
Are you registered with the Government’s WELFARE TO WORK/NEW DEAL Scheme? YES/NO
FOR MEDICAL/NURSING/PROFESSIONAL STAFF ONLY
Details of registration with professional body e.g. Nursing and Midwifery Council/GMC/GDC
Please state whether full, limited or temporary

Number:
FOR CAREER GRADE MEDICAL STAFF ONLY
Are you on the GMS Specialist register/hold CCST? YES/NO Date:
……………………………………………………………….
FOR TRAINING GRADE MEDICAL STAFF ONLY
Do you hold a permit free visa? YES/NO Period remaining: …………………………………………………………….
2. EDUCATION/TRAINING
SECTION A) GENERAL EDUCATION (AFTER THE AGE OF 11)
Schools/Colleges/Other / CSE/GCE/GCSE subjects
or equivalent / Grades/Level and date
Obtained
SECTION B) FURTHER EDUCATION
PROFESSIONAL QUALIFICATIONS Degrees, diplomas and other qualifications held or being studied for
(please* qualifications gained by examination)
University or College or Training Organisation / Subject/Course title / Qualification and level attained / Length of course
(F/T or P/T) / Date obtained
SPECIALIST TRAINING
Please give details of any special/vocational training and membership of professional, specific or other bodies (give registration numbers if appropriate).
SHORTLISTED CANDIDATES WILL BE EXPECTED TO BRING ORIGINAL QUALIFICATION CERTIFICATES TO THE INTERVIEW
3. EMPLOYMENT HISTORY
EMPLOYMENT
Last or present employer
Name and address
Present grade and salary: ………....
……………………………………. / Post/Grade / Brief description of duties / Dates From / Dates To
Reason for leaving:
PREVIOUS POSTS
(most recent first)
N.B. All applicants must include details of all locum/temporary/fixed term appointments of greater than 1 week held within the last 2 years. Attach additional sheet if required.
Name & address of employer / Post/Grade / Reason for leaving / Dates From / Dates To
4. WHY SHOULD YOU BE CONSIDERED FOR THIS POST?
All applicants are shortlisted against the person specification enclosed which indicates those criteria to be assessed from the application form.
Please use the space below to provide as much information as possible to demonstrate how you meet these criteria (continue on the back sheet if necessary).
Only those applicants who have met the relevant criteria will be shortlisted for interview.
5. FURTHER ESSENTIAL INFORMATION
SECTION A) Rehabilitation of Offenders Act 1974 (declaration of criminal convictions)
Before answering the question below, please note the post you have applied for is exempt from The Rehabilitation of Offenders Act
1974
This is because the job is concerned with the provision of health services which involves access to patients.
You must therefore declare on the application form the details of any previous conviction, whether spent or otherwise.
This information does not affect the shortlisting process. However, it is the Hospice’s policy that all candidates are asked at interview, whether they have ever been convicted of a criminal offence, or issued with an official caution by the police. In addition, successful candidates whose posts involve access to children or vulnerable adults are required to undergo a criminal records bureau disclosure check as a condition of their employment.
Failure to disclose details of any conviction/police caution may, where an applicant has been appointed and this subsequently comes to light, result in their summary dismissal by the Hospice.
“If in doubt declare it”
You must declare any convictions, including those normally considered spent under the 1974 Act (Rehabilitation of Offenders Act Exceptions Order 1975).
Have you ever been convicted of any criminal offence, either in this country or overseas? (This does not include driving offences that did not result in disqualification)
Please tick the appropriate box:-

Yes No
If yes, please give details:
SECTION B) Have you ever been, or are currently the subject of, any police investigation in this country or overseas?

Yes No
If yes, please give details:
Staff appointed will be subject to a Criminal Records Bureau check via the Disclosure Service. The job description and person specification for the post for which you are applying indicates if Disclosure will be sought and the relevant level of Disclosure.
SECTION C) Do you have any current disciplinary warning on file or have any disciplinary investigations/proceedings
pending at the present time?

Yes No
If yes, please give details:
SECTION D) Do you have any proceedings/prescribed conditions on your professional registration
e.g. Nursing and Midwifery Council/GMC/GDC at the time of this application?

Yes No
If yes, please give details:
SECTION E) Have you ever been or are currently the subject of fitness to practice proceedings by any body having
regulatory functions in this or in any other country?

Yes No
If yes, please give details:
The information will be treated in confidence and will not debar you from appointment unless the selection panel considers that it renders you unsuitable for appointment. In reaching such a decision the Hospice will consider the nature of the conviction/action, how long ago it took place and any other factors which may be relevant.
FAILURE TO DISCLOSE A CRIMINAL OFFENCE, HAVING BEEN BOUND OVER OR CAUTIONED, OR THAT YOU ARE CURRENTLY THE SUBJECT OF CRIMINAL PROCEEDINGS WHICH MIGHT LEAD TO A CONVICTION, AN ORDER BINDING YOU OVER, OR A CAUTION, OR FITNESS TO PRACTICE PROCEEDINGS UNDERTAKEN OR BEING UNDERTAKEN BY AN APPROPRIATE LICENSING, OR REGULATORY BODY, MAY DISQUALIFY YOU FROM APPOINTMENT, OR RESULT IN SUMMARY DISMISSAL/DISCIPLINARY ACTION AND REFERRAL TO THE APPROPRIATE REGULATORY BODY FOR CONSIDERATION IF SUCH A DISCREPANCY CAME TO LIGHT, SUBSEQUENT TO YOUR EMPLOYMENT.
6. REFERENCES
Please give a name, title and (full) addresses of two people from whom references may be obtained. At least one must be your manager/supervisor from your present or most recent employer/educational establishment. Please do not give a member of your family.
Medical Staff only: Please complete all 3 boxes when applying for a career grade (e.g. Consultant or Staff Grade).

7. DECLARATION
To the best of my knowledge, the details given in this application form are accurate and truthful.
I understand that any misrepresentation found, or omissions discovered after appointment, may lead to dismissal.
Signed: ……………………………………………………………… Date: …………………………………………………..

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