Driving (Only Complete This Section If This Is an Essential Requirement for the Role)

Application for employment
Before you begin: /

Please read all the instructions carefully before completing this form
If completing this form by hand, please use black ink
Applications may not be considered if full details are not given

Job applied for:
Full-time / Part-time / Bank/casual
Surname:
Forename or initials:
Address: / Contact details: Please tick your preferred contact details. Calls to work numbers will be made discreetly.
Telephone
(home)
Telephone
(work)
Mobile
Postcode: / Email
Are you either employed or volunteering with Princess Alice Hospice already? / Yes / No
If yes, in what capacity: / Member of staff / Volunteer
Are you related to a member of staff or a volunteer? / Yes / No
How did you find out about this job?
If offered the position, do you intend to continue working in any other capacity? / No / Yes / If yes, how many hours per week?
Please indicate if you are presenting as a job share applicant: / Yes / No

Driving (only complete this section if this is an essential requirement for the role)

Do you hold a current driving licence to drive in the UK? / Yes / No
If yes, what type of licence is it? / Full licence / Provisional
Do you have use of a car during working hours? / Yes / No
Do you have any driving licence endorsements? / Yes / No
If yes, please give details of any points or driving convictions, including any pending convictions. Please see the guidelines on the Rehabilitation of Offenders Act 1974 (exceptions) Order 1975 on Page 9

Qualifications

If qualifications are an essential requirement for the role, you will be asked to present the original documents issued by the examining body before your appointment is confirmed.

School / College / Qualifications: (from secondary education level to include degrees, vocational or equivalent qualifications) / Grade / level / Date
Professional membership: (please include job related qualifications and membership of professional bodies) / Grade / level
Registration body:
Training: / Please list courses attended during the last five years that are relevant to this post / Grade / level / Date
Computer literacy: (please specify the software and level of competence)
Please list any other training you feel is relevant:

Employment history

Please give details of all previous employment, full and part-time, paid or unpaid, including those in a voluntary capacity. This must cover all periods and account for any gaps in employment.

Present (or most recent employer)

Name of employer:
Address of Employer:
Nature of Business:
Position(s) Held: / Month / Year
From:
To:
Summary of main duties:
Reason for leaving:

Previous employment

Name of employer:
Address of Employer:
Nature of Business:
Position(s) Held: / Month / Year
From:
To:
Summary of main duties:
Reason for leaving:

Previous employment

Name of employer:
Address of Employer:
Nature of Business:
Position(s) Held: / Month / Year
From:
To:
Summary of main duties:
Reason for leaving:

Previous employment

Name of employer:
Address of Employer:
Nature of Business:
Position(s) Held: / Month / Year
From:
To:
Summary of main duties:
Reason for leaving:

Please continue on a separate sheet if necessary

References

Please give the names, addresses and occupations of two referees who you agree can be contacted if a verbal, conditional offer of employment is made and accepted. We will not contact your referees until an offer has been made. The first referee must be your present or most recent employer. The second should be someone able to comment on your ability to do the job. The second referee should not be a relative.

Name: / Name:
Occupation: / Occupation:
Work address: / Address:
Telephone number: / Telephone number:
Email: / Email:
How long have you
known this referee? / How long have you known this referee?
In what capacity? / In what capacity?
Personal experience, skills and knowledge
Please use this space to give examples of your skills and experience relevant to this application. Give details of the experience gained in your most recent job, including any voluntary work experience. Please match your information to the job description and person specification (continue on a separate sheet if necessary).

Asylum and Immigration Act 2006

Are you legally eligible to take up employment in the UK? / Yes / No
Please state what documentation you can provide to demonstrate this.
For details of valid identity documents, please refer to the UK Border Agency website at
Do you require a Tier 2 Certificate of Sponsorship (formerly a Work Permit) to accept this post? / Yes / No
Expiry date (if applicable) / Month / Year
Do you have student status?
Overseas students who are not European Economic Area nationals who are studying in UK institutions must not work for more than 20 hours per week. / Yes / No

In order to comply with its legal duty under the Asylum and Immigration Act 2006, the Hospice will seek confirmation of an applicant's entitlement to work in the United Kingdom as a condition before any offer of employment can be confirmed.

Data protection statement

The information that you provide on this form and that obtained from other relevant sources will be used to process your application for employment. Job applications are normally retained for 12 months from the date of interview. The personal information that you give us will also be used in a confidential manner to help us monitor our recruitment process.

If you succeed in your application and take up employment with us, we may also use the information if there is a complaint or legal challenge relevant to this recruitment process. Your application will be retained on your personal file.

We may check the information collected with third parties. We may also use or pass to third parties, information to prevent or detect crime, to protect public funds, or in other ways as permitted by law.

By signing this application form we will be assuming that you agree to the processing of sensitive personal data (as described above), in accordance with our registration with the Information Commissioner.

Declaration

I declare that all the above information in this application, and in any Curriculum Vitae attached, is true, accurate and complete. Any misrepresentation of information may invalidate my application, or lead to my summary dismissal after appointment.

Signature: / Date:

Returning you application

Please return this application form to the following address:

email:

post:Princess Alice Hospice Distribution Centre, Unit 4c, 43-45 Central Avenue, West Molesey, Surrey, KT8 2QZ

Equality Monitoring Form
Before you begin: /

This form will remain confidential within the People Services Team and will not be circulated to those involved in the shortlisting or interview process
Personal details requested below will only be used if you are appointed
Details are used for monitoring purposes under our Equality and Diversity Policy

Job applied for:
Surname:
Title: / Forenames:
Former surnames:
Gender: / Male / Female / Age:
Date of birth: / Day / Month / Year

How do you identify your ethnic group?

Please tick ALLthe relevant boxes and indicate which options apply to you. These categories are approved by the Commission for Racial Equality.

White: / Please specify further: British☐ English ☐ Irish ☐ Scottish ☐ Welsh ☐ Other Click here to enter text.
Mixed: / Please specify further: White & Asian ☐ White & Black African☐ White & Black British ☐ White & Black Caribbean ☐ Other Click here to enter text.
Asian: / Please specify further: Bangladeshi ☐ British ☐ Indian ☐ Pakistani ☐Other Click here to enter text.
Black: / Please specify by further: African ☐ British ☐ Caribbean ☐
Other Click here to enter text.
Chinese: / Please specify further: Chinese ☐ Other Click here to enter text.
Other: / Please specify: Click here to enter text.
Prefer not to say:
Nationality: / Prefer not to say:

Applicants with Disabilities

The Hospice welcomes applications from people with disabilities. The Equality Act 2010 defines disability as ‘a physical or mental impairment that has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities’. Employees with a disability or long-term health condition are entitled in law to ‘reasonable adjustments’. Therefore we are interested in collecting information about disabilities that may require such adjustments.

Below is a list of some medical impairments that could cause people to describe themselves as ‘having a disability’. It is not an exhaustive list, and is given for guidance only:

Hearing, speech or visual impairments (wearing glasses or contact lenses is not normally considered a disability)
Physical mobility problems, coordination or dexterity (for example as a result of polio, spinal injury, severe back problems, RSI, etc.)
Mental health (for example schizophrenia, severe depression, severe phobias)
Learning difficulties / disabilities (for example Down’s Syndrome, dyslexia, autistic spectrum disorder)
Long-term conditions such as: diabetes, epilepsy, chronic heart disease, haemophilia, asthma, cancer, HIV
Other

Do you consider yourself to have a disability?Are you Registered Disabled?What is the nature of your disability?

YES / NO / PREFER NOTYES / NO / PREFER NOT

TO SAY TO SAY

Please indicate below if you have any special requirements with regard to the interview process.

A member of the People Services team will discuss such adjustments with you in more detail if you are invited to interview. There will also be an opportunity to discuss any adjustments to the workplace or working arrangements that may be required to enable you to carry out your duties, if you are appointed. The Hospice is committed to creating an environment where barriers are removed for disabled people.

Rehabilitation of Offenders Act 1974 (exceptions) Order 1975

The Hospice is exempt from the provisions of the Rehabilitation of Offenders Act 1974. Applicants who want to work for the Hospicein Regulated Activities are not entitled to withhold information about spent or unspent criminal convictions however long ago they occurred. Successful candidates for certain posts will be subject to a Disclosure and Barring Service (DBS) check.

It is a requirement of the Disclosure and Barring Service (formerly the Criminal Records Bureau) Code of Practice that all Registered Bodies must treat Disclosure applicants who have a criminal record fairly and do not discriminate because of a conviction or other information revealed. It also obliges Registered Bodies to have a written policy on the recruitment of ex-offenders. Princess Alice Hospice has a Disclosure and Barring Service (DBS) policy that includes a section on the recruitment of staff who declare a criminal conviction or caution.

The Hospice actively promotes equality of opportunity for all with the right mix of talent, skills and potential including those with a criminal record that does not create risk to vulnerable adults/children. Managers select all candidates for interview based on their skills, qualifications and experience.

All applicantsfor Regulated Activities, who are called for interview must provide details of any previous criminal record. This information must be sent under separate, confidential cover, to a designated person within the HR Department, and we guarantee that this information is only seen by those who need to see it as part of the recruitment process. The Hospice will ensure that all those who are involved in the recruitment process have been suitably trained to identify and assess the relevance and circumstances of offences. We also ensure that they have received appropriate guidance and training in the relevant legislation relating to the employment of ex-offenders, e.g. the Rehabilitation of Offenders Act 1974.

We would like to make all applicants who are subject to a DBS check aware of the existence of the Disclosure and Barring Service Code of Practice and a copy is available on request.

W\HR\Recruitment and Selection

January 2015

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