St Marks Community Centre
218 Tollgate Road
Beckton
London E6 5YA
email:
tel: 020 7474 3176
APPLICATION FORM
CONFIDENTIAL Detached Section Reference Number
POST / Healthwatch Manager (Waltham Forest) Maternity Locum
CLOSING DATE FOR APPLICATIONS / Deadline 22nd September 2016 no later than 12 noon
Please return applications to Manjit Notta at the address provided above.
Or email completed applications to
Surname:
First Names:
Address:
Telephone No and email: / (Tel No)
(Email)
Please indicate what period of notice is required by your current employers
5 - References (see note 5)
Please give the names and addresses of two referees: (one of whom should be your present or latest employer)
1 / 2
Name:
Position:
Company / Organisation:
Address:
Telephone no:
Email address:
In what capacity do you know this person:
Tick as appropriate: / / Do not contact until offered the post / / Do not contact until offered the post
/ Can be contacted now / / Can be contacted now
6 - If you have been convicted of any criminal record which is not spent, as defined by the rehabilitation of offenders act 1974, please give details: (see note 6)
Signed:……………………………………………………………..…… Dated:……………………………….
Please note: Giving incorrect information on this application could lead to termination of employment
Equal opportunities monitoring form
We hope you will assist us by filling out this monitoring form. This information is being gathered to monitor the operation of our recruitment procedure, and the effectiveness of advertising media and for no other purpose. The data will not be taken into account in shortlisting, because it is detached form the form before the panel see it. If you prefer not to answer any question this will not affect your application.
Are you Male Female
Ethnic origin: The following categories have been selected to reflect the Commission for Racial Equality and the Department of Health’s recommendations.
What is your ethnic group?
a) White¨ British
¨ Irish
¨ Any other white background (Please write in below) / b) Mixed
¨ White and Black Caribbean
¨ White and Black African
¨ White and Asian
¨ Any other mixed background (Please write in below)
c) Asian or Asian British
¨ Indian
¨ Pakistani
¨ Bangladeshi
¨ Any other Asian background (Please write in below) / d) Black or Black British
¨ Caribbean
¨ African
¨ Any other Black background (Please write in below)
e) Chinese or other ethnic group
¨ Chinese
¨ Any other group (Please write in below)
Disability: Disability is defined as a physical or mental impairment, which has a substantial and long term effect on a person’s ability to carry out their day to day activities.
In these terms, do you consider you have a disability Yes No
How did you hear about this vacancy?
Advert (which paper/journal/website?
Other source – please specify
SECTION USED FOR SHORTLISTING REFERENCE NUMBER
A - Latest Employment
Name & Address of Employer / From / To / Post & brief outline of duties
Reason For Leaving:
Latest Salary:
B - Previous Employment (see note 6)
Name & Address of Employer / From / To / Post & brief outline of duties
Reason For Leaving:
Previous Employment
Name & Address of Employer / From / To / Post & brief outline of duties
Reason For Leaving:
please continue on a separate sheet if necessary
2 - Qualifications and training undertaken of relevance to the post applied for:
3 - Describe any community activity or voluntary work you have been involved in which is of relevance to the post: (please give dates and name of organisation)
4 - Please state under each of the criteria listed what relevant skills or experience you would bring to this job: please continue on a separate piece of paper if necessary (see note 7)
NOTES FOR COMPLETING THE APPLICATION AND RETURNING THE FORM
1. Please type or write in black ink. All forms are photocopied and black photocopies much better than other colours.
2. Applicants are welcome to continue on additional sheets of paper if there is insufficient space on the application form.
3. Do not submit your CV in lieu of completing the application form. Such applications will not be considered.
4. Do not send copies of references or certificates with your application.
5. Please assist us to monitor our recruitment process by completing the equal opportunities monitoring section. It is used for monitoring only and is not seen by the recruitment panel.
6. QUESTION 1b – PREVIOUS EMPLOYMENT – please give in date order (starting with the most recent), the name of your previous employer(s), the dates employed, the title of the post with a brief outline of the duties, and the reason for leaving. Please continue on additional sheets if necessary.
7. QUESTION 4 – The skills and experience could have been gained in voluntary or paid work. When completing this section please give examples of your skills and experience in relation to the requirements listed as these form the basis for shortlisting for this post.
8. QUESTION 5 – Please indicate on the application form if you want to be notified prior to referees being contacted or if you would prefer referees not to be contacted until you have been offered the post.
9. QUESTION 6 – A criminal record will not automatically debar you from consideration for employment. If the Forum has any concerns as to the effect a criminal record would have on your ability to carry out the functions of the post they will be raised with you.
10. Normal office hours are 10.00am – 6.00pm, Monday to Friday, however adjustments can be arranged to take into account child/family care responsibilities.
If at any stage during the recruitment process you consider that you have been treated unfairly please contact the Chair of the Forum in confidence.
Return application form to: Manjit Notta, The Forum for Health and Wellbeing, St Mark’s Centre, 218 Tollgate Road, Beckton, London E6 5YA or email applications to
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