Larwood and Village Surgeries, Larwood Surgery, 56 Larwood, Worksop Notts S81 0HH

Larwood Health Partnership,56 Larwood, Worksop, Notts. S81 0HH

EDUCATION

Place / From / To / Course/Subject / Result/Grade

CURRENT POST

Name of organisation
Address
Job Title Position held/ Grade of position held
Date of Appointment
Salary / Earnings
Notice required to terminate employment
Summary of duties:
Reason for wishing to leave:

PREVIOUS EMPLOYERS -List your last employers, starting with the most recent (include vacation work)

Employer from to
Address
Job Title
Salary
Duties
Reason for leaving
Employer from to
Address
Job Title
Salary
Duties
Reason for leaving
Employer from to
Address
Job Title
Salary
Duties
Reason for leaving
Employer from to
Address
Job Title
Salary
Duties
Reason for leaving
Employer from to
Address
Job Title
Salary
Duties
Reason for leaving

Please continue on a further sheet if necessary

HEALTH

If you have a disability, do you require any reasonable adjustment to be made during the recruitment process, including interview? If so please give details
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REFERENCES

Please give names and contact details of two people who have agreed to supply references, one of which should be your most recent employer, your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. Where it is not possible to obtain any employer reference then please obtain two personal references (not related to or involved in any financial arrangement with you).
Please note, all reference requests will be sought and employment history verified through the organisation’s Human Resources Manager, therefore please provide full contact details.
Name:
Address: email address:
How do you know them:
Tel No:
How long has he/.she known you:
*Work related or Character/academic (please indicate which type of reference)
Name:
Address: email address:
How do you know them:
Tel No:
How long has he/.she known you?
*Work related or Character/Academic reference (please indicate which type of reference)

Please give below any other information in support of your application including skills, knowledge and achievements which you feel are relevant

STATEMENT BY APPLICANT

Please Return to Sharron Wood, Human Resource Manager, Larwood Health Partnership, 56 Larwood Avenue, Worksop. Notts S81 0HH or email to

Monitoring Form

Larwood Health Partnership Surgeries is an equal opportunity employer and are determined to ensure that no applicant or employee receives less favourable treatment on the grounds of sex, disability, religious belief, marital status, colour, race or ethnic origins.

The information you complete on this form will not be available to the short-listing panel and is used purely for monitoring purposes in an anonymous format.

Please state the position you have applied for

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Please state whether you are male or female

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Please state whether you have a disability, and if so what that disability is

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Please state your ethnic origin

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Please state your age …………………………………………………….

Please state how you came to know of this vacancy

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Today’s Date …………………………………

Declaration Form

CONFIDENTIAL

Before you can be considered for appointment in a position of trust with Larwood Health Partnership we need to be satisfied about your character and suitability.

Please read the following notes carefully before completing this Declaration Form.

Larwood Health Partnership aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, martial status, religion, disability, sexual orientation or age. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other information declared.

Prior to making a final decision concerning your application we shall discuss with you any information declared by you that we believe has a bearing on your suitability for the position. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event, you remain free to discuss any of that information or any other matter that you wish to raise. As part of assessing your application, we will only take into account relevant criminal record and other information declared.

The Data Protection Act 1998 requires us to advise you that we will be processing your personal data and, generally, to obtain your consent before processing personal data about you. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 1998 defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental health, sexual life, commission or alleged commission of offences and any proceedings for any offence committed or alleged to have been committed.

The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998, and may also be used for the purpose of determining your application for this position and may also be used for the purpose of enquires in relation to the prevention and detection of fraud. Once a decision has been made concerning your appointment, for successful applicants the declaration will be retained on their personal file, if unsuccessful, the declaration will be destroyed after 6 months. This declaration will be kept securely and in confidence, and access to it will be restricted to designated persons within Larwood Health Partnership who are authorised to view it as a necessary part of their work.

Please answer all of the following questions. If you answer “Yes” to any of the questions, please provide full details in the space indicated. Please also use the space below to provide any other information that may have a bearing on your suitability for the position for which you are applying. You may continue on a separate sheet if necessary, and you may attach supplementary comments should you wish to do so.

Because of the nature of the work for which you are applying, this post is exempt from the provisions of section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants are, therefore, not entitled to withhold information about convictions which for other purposes are "spent" under the provisions of the Act, and, in the event of employment any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the order applies.

You however do not have to disclose ‘protected cautions and convictions’.

Protected Cautions and Convictions

Unless you were convicted for an offence listed in art.2A(5) of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (found at: You do not need to disclose the following ‘Protected Convictions’

Where five years and six months have passed since the date of the conviction if you were under 18 years at the time of the conviction
Where eleven years or more have passed since the date of the conviction if you was 18 years or over at the time of the conviction
The conviction did not result in a custodial sentence
You have not been convicted of any other offence at any time

Where two years or more have passed since the date on which the caution was given if you were under 18 years at the time the caution was given
Where six years or more have passed since the date on which the caution was given if the job applicant was 18 years or over at the time the caution was given
Where the caution was not given for an offence listed in art.2A(5) of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975

The following website also informs you of offences that will never be filtered from a DBS check

Do you have ‘unprotected’ cautions and convictions?

Yes

If Yes please provide details of the nature of the caution or conviction, the date on which you were cautioned or convicted, and details of any on-going proceedings by a prosecuting body:

Are you aware of any current police investigations in the United Kingdom or in any other country following allegations made against you?

Yes

If YES, please include details of the nature of the allegations made against you, and if known to you, any action to be taken against you by the police.

Have you ever been dismissed by reason of misconduct from any employment, office or other position previously held by you?

Yes

If YES, please include details of the employment, office or position held, the date that you were dismissed and the nature of allegations of misconduct made against you.

Have you received any verbal or written warnings against you from any employer within the last 2 years.

Yes

If Yes, please provide details of the offence and the outcome of any investigations.

Declaration By Applicant

I have read the Guidance Notes for Applicants that accompanied my application form, and I consent to the information provided in this Declaration Form being used by Larwood Health Partnershipfor the purpose of assessing my application and for enquiries in relation to the prevention, and detection, of fraud.

I confirm that the information that I have provided in this Declaration Form is correct and complete. I understand and accept that if I knowingly withhold information or provide false or misleading information this may result in my application being rejected, or if I am appointed, in my dismissal, and I may be liable to prosecution.

Please sign and date this form.

SIGNATURE ………………………………………………. DATE ………………………………….

NAME (in block capitals)

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