Job Application Form s12

CONFIDENTIAL

JOB APPLICATION FORM

Title of Post ……………………………………………………………………………………

Based at ……………………………………………………………………………………

PERSONAL DETAILS

Name in Full ……………………………………………. Title (Dr/Mr/Mrs/Ms etc) …….…

Address ……………………………………………………………………………………….

……………………………………………………………. ……………………………………

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(post code) ……………………………………………… ……………………………………

Telephone No ……………………………………………. (Home) ………………………..

……………………………………………………………. (Work) …………………………

How did you hear of the vacancy? ………………………………………………………..

Do you hold a valid current driving licence? ………………………………………………

Do you have any relatives/partners who are currently employed within the Company? Yes/No If yes, please provide the name and home/department they are based in.

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(Note: if you are invited to an interview, you will be asked to bring along documentation in order to prove that you are permitted to work in the United Kingdom. Please see enclosure for further information.)

REFERENCES

Please give full name and address of two referees, one of whom must be your present (or, if unemployed, your most recent) employer.

Name of Employer…………………………… Name of Company

Address ……………………………………….. …………………………………………….

………………………………………………………………….(post code) …………………

Occupation ………………………………Tel No … ………………………………………..

Name of employer…………………………… Name of Company

Address ……………………………………….. …………………………………………….

………………………………………………………………….(post code) …………………

Occupation ………………………………Tel No … ………………………………………..

May we approach your referees prior to interview? Yes/No

EDUCATION

PROFESSIONAL QUALIFICATIONS

N.B. EVIDENCE OF QUALIFICATIONS WILL BE REQUIRED, QUALIFIED NURSES MUST PRODUCE REGISTRATION/ENROLMENT CERTIFICATES PRIOR TO EMPLOYMENT

UKCC PIN NUMBER ……………………………………… EXP. DATE ……………….

ANY FURTHER COURSES

Any Other Languages Spoken:………………………………………………………………..

EMPLOYMENT HISTORY

PLEASE GIVE DETAILS OF FULL EMPLOYMENT HISTORY OR ENCLOSE A RECENT CV (most recent first, ensuring to account for any gaps in employment, please continue on a separate sheet if necessary). Please include months and years

TITLE OF POST …………………………………… EMPLOYER ………………………

FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

TITLE OF POST ……………………………………. EMPLOYER ……………………..

FROM ………… TO ………… FULL OR PART-TIME ………….. SALARY …………

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

TITLE OF POST …………………………………… EMPLOYER ………………………

FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

TITLE OF POST …………………………………… EMPLOYER ………………………

FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

TITLE OF POST …………………………………… EMPLOYER ………………………

FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

TITLE OF POST …………………………………… EMPLOYER ………………………

FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

TITLE OF POST …………………………………… EMPLOYER ………………………

FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

TITLE OF POST …………………………………… EMPLOYER ………………………

FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

TITLE OF POST …………………………………… EMPLOYER ………………………

FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….

MAIN RESPONSIBILITIES ……………………………………………………………….

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REASON FOR LEAVING …………………………………………………………………

REHABILITATION OF OFFENDERS ACT

Due to the activities of The Regard Partnership Ltd, under the Rehabilitation of Offenders Act (1974 and 1975), you have a legal obligation to disclose any criminal convictions you may have, irrespective of whether or not they would be considered ‘spent’ in other types of industry.

Any such information will be kept in strict confidence and will only be taken into account in respect of your suitability for the position for which you are applying and/or for which criminal convictions must be considered. Please note that successful candidates will be required, for verification purposes, to apply to the Disclosure and Barring Service for an enhanced disclosure details of which will be made available at the appropriate time.

Have you been known by any name other than that shown on the application form (e.g. maiden name, adoptive or common-law name for example)? YES/NO

If yes, please provide details:

…………………………………………………………………………………………………..

Should employment be offered, it is on condition that any future convictions or cautions for a criminal offence must be notified to the management immediately. Each case would be taken on its merits and suspension or dismissal would not automatically follow. Failure to disclose, however, may well result in dismissal.

Have you resided at any address other than that quoted on your application for within the last 5 years? YES/NO If yes please give details:

…………………………………………………………………………………………………..

Do you have any convictions or cautions (current or spent since the age of 16)? YES/NO

Are you currently the subject of any criminal proceedings (for example charged or summonsed but not yet dealt with) or any police or other official or regulatory body investigation?

If the answer to either question is YES, please give details below (please continue on a separate sheet if necessary)

Have you ever been subject to a SOVA/POVA/POCA investigation or police investigation due to an allegation of abuse against a vulnerable person? YES/NO If yes, please give details:

…………………………………………………………………………………………………………

PLEASE GIVE ANY ADDITIONAL INFORMATION WHICH YOU THINK MAY BE RELEVANT IN SUPPORT OF YOUR APPLICATION. (Continue on a separate sheet if necessary)

DECLARATION

I understand that if I am offered employment, the information submitted in my application will form the basis of my contract of employment with The Regard Partnership Ltd and that if it is subsequently discovered that I have wilfully or negligently given false information or withheld any information for whatever reason, I will be liable for immediate dismissal and may also be prosecuted. All the information given by me within this application is true to the best of my knowledge and belief.

Name ………………………………………………………… Date ……………………….

Name ………………………………………………………… Date ……………………….

(To be witnessed by parent, guardian or appropriate adult if applicant is under 17yrs age)

Relationship to applicant:

Please email this form to

FOR OFFICE USE ONLY

Outcome of interview ……………………………………………………………………….

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Documents seen by ………………………………………………………………………….

Passport Photo ID

Birth Certificate

Others ……………………………………………………………………………………….

ACH 6 of 6 Updated: Dec 2014