This form will be photocopied. All information entered on this form will be validated.

APPLICATION FORTHE POST OF: ______

  1. Personal Details.

Surname ______Title: Dr Mr Mrs Miss Ms
(Please indicate)
Forename(s)______
Address______
______
______
E-mail address______
Telephone Home No. ______Work ______Mobile ______
National Insurance Number______
If not a UK national do you already have a work permit for the UK YESNO NA
(Please indicate)
Do you have a valid driver's licence?YES/NO
  1. Present Employment.

Current Employer's Name and Address ______
______
Job Title ______Date Appointed ______
Outline of responsibilities: ______
______
______
______
Total Salary ______
Period of Notice Required______
  1. Previous Employment Recordstarting with your most recent post.

Employer / Job Title and Responsibilities
Name:
Address:
Salary:
From: To:
Reason for Leaving:
Name:
Address:
Salary:
From: To:
Reason for Leaving:
Name:
Address:
Salary:
From: To:
Reason for Leaving:
Name:
Address:
Salary:
From: To:
Reason for Leaving:

Previous employment continued (add additional pages as required).

Employer / Job Title and Responsibilities
Name:
Address:
Salary:
From: To:
Reason for Leaving:
Name:
Address:
Salary:
From: To:
Reason for Leaving:
Name:
Address:
Salary:
From: To:
Reason for Leaving:
Name:
Address:
Salary:
From: To:
Reason for Leaving:
  1. Academic Qualifications

Institution /

Qualification(s)including subject(s)

/ Date / Result

5.Professional Qualifications, Training and Relevant Professional Development Activities (please omit courses of less than one day).

Brief Description / Date / Organising Body
  1. Personal Statement: To be completed below (you may add additional pages if required) or as a letter of application.

Please outline the particular skills, knowledge, abilities and qualities that you have that enable you to meet the needs of the position you are applying for as detailed in the Advert, Person Specification and Job Description.
7.Additional Information
Nationality:
Do you require certificate of sponsorship to work in the UK?
If yes, do you currently have a work permit/certificate of
sponsorship?
Please list any professional
bodies of which you are a
member, stating type of
membership and whether it is
dependent on qualification or
examination
If you work within an education, health or social care profession, please identify any regulatory body you are registered with?
8.Please Nominate Two Referees

If you are in employment your first referee should be your current employer (Headteacher or equivalent). If there are reasons for this not being possible, a senior member of management should be identified. Your secnd referee may be a previous employer, line manager or a personal reference. All references will be taken up as and when appropriate.

First RefereeSecond Referee

Name and Address:Name and Address:

Telephone Number:Telephone Number:

Email address:Email address:

Occupation:Occupation:

Relationship to you:Relationship to you:

9.Self declaration of suitability to work in posts requiring a Disclosure and Barring Service Check

As the work of this post involves working with children, other vulnerable groups or in a position of trust and meets the definition of Regulated Activity (as defined in the Safeguarding Vulnerable Groups Act 2006 asamended by the Protection of Freedoms Act 2012) the relevant barred list(s) for children and adults will also be checked. Youmust disclose details of all unfiltered reprimands, formal warnings, cautions and convictions as these will be disclosed by the DBS it is exempt from theprovisions of the Rehabilitation of Offenders Act 1974 Health FuturesUTC will request a Disclosure and Barring Service (DBS)certificate revealing criminal convictions. You should note that disclosing a conviction does not necessarily bar you from appointment.

For information regarding filtering of convictions please see:

Do you have any convictions, cautions, reprimands or final warnings which would not be filtered in line with current guidance? Where the answer is yes you should disclose all such items below.

YES/NO

Are you currently involved in any Court or Tribunal Proceedings or, as far as you are aware, are any such proceedings pending?

YES/NO

Have you at any time been barred from teaching or working with young people by any regulatory authority?

YES/NO

I declare that the information contained in this application form is true and complete and I acknowledge that it forms the basis on which Health Futures UTC is considering my application. I accept that if it shall subsequently be established that I have given false or misleading statements or information in any way and I have been offered a post or appointed to any position then theHealth Futures UTCshall be entitled forthwith to withdraw such an offer or terminate my contract of employment.

Signature______

Name Printed______

Date______

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