In confidence:
Position Applied for:
1 PERSONAL DETAILS
Title: (Mr / Mrs / Miss / Ms etc.)
Surname:
First names:
Previous Surname:
…………………………………………………………………
…………………………………………………………………
…………………………………………………………………
………………………………………………………………...
Postcode: ……………………………
Address:
Day time Evening
Mobile
Telephone number:
Email address:
2 PRESENT EMPLOYMENT DETAILS
…………………………………………………………………
…………………………………………………………………
…………………………………………………………………
…………………………………………………………………
…………………………………………………………………
Name and Address
of present employer:
Title of post held: Present salary:
Date appointed: Period of notice required:
Duties and
responsibilities
of post and reasons for leaving
3 PREVIOUS EXPERIENCE OF EMPLOYMENT
(Please give details of previous posts held over the last ten years, the most recent shown first)
Employer’s name and address / Dates / Position and brief outline of responsibilities / Reason for leavingFrom / To
4 QUALIFICATIONS / TRAINING
Please give details ofcourses including day release, part-time, correspondence / Dates / Type of training, subjects studied and
qualifications (please add UKCC PIN and expiry date if applicable)
From / To
5 HEALTH
Do you have a disability or health issue which could affect your ability to do this work in any way.
YES NO
If yes, please
give details
6 PERSONAL STATEMENT
Please use this space to give further details in support of your application. In particular, say why you want the job and what relevant experience, training and skills you have. You may wish to include details of any voluntary work, outside interests or activities, special skills or qualities you have. Continue on a separate sheet of paper if necessary.
7 REFERENCES
One reference MUST include your present employer. This will not be requested without your permission
Previous employer / personal
2 Name: ………………………………………………
Address: ………………………………………………
………………………………………………
………………………………………………
………………………………………………
Tel No. : ………………………………………………
Fax No. : ………………………………………………
Present / previous employer
1 Name: ………………………………………………
Address: ………………………………………………
………………………………………………
………………………………………………
………………………………………………
Tel No. : ………………………………………………
Fax No. : ………………………………………………
8 REHABILITATION OF OFFENDERS ACT 1974
Do you have a prosecution pending or have you ever been convicted at a court or cautioned or arrested by the police for any offences? YES NO
If yes, please
give details:
You should note that this post is exempt from the provisions of Section 4 (2) of the Rehabilitation of Offenders Act 1974, applicants are therefore not entitled to withhold information relating to convictions which for other purposes have ‘expired’ under the provisions of the Act. In the event of employment, failure to disclose such information could result in dismissal.
9 GENERAL INFORMATION
Do you hold a current driving licence? YES NO
Do you have a car available for your use? YES NO
I understand that the appointment if offered will be subject to the information given on this form being correct. I also understand that employment will be subject to receipt of satisfactory references, medical clearance and a police check.
Signature: ………………………………………………………………………
Date: ………………………………………………………………………
Where did you see this position advertised?
Please return form to:
Gwendoline Nightingale
The Nightingale Centre
1 The Street
Framingham Earl
NR14 7QY
or email
Date Received:
THE NIGHTINGALE CENTRE
Monitoring Form
The information given on this form is confidential and is purely for the purpose of monitoring our equal opportunities policy. This form will be detached by the Centre Manager and will not be taken into account when making the appointment.
Surname …………………………………………… Initials ……………………….
Post applied for ………………………………………………………………………
Where did you see this post advertised ……………………………………………
Are you male or female
Date of birth ………………………. Nationality …………………………………..
Do you consider yourself to have a disability? Yes No
In accordance with the Policy on the Employment of People with Disabilities and to assist the Nightingale Centre in pursuing its commitment to ensure that people with disabilities are able to participate as fully as possible in the recruitment and selection process and in the employment at the Centre, are there any adjustments that need to be made for the purpose of:
The interview?
……………………..………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
The job?
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
How would you describe your ethnic origin?
White / European Pakistani Black African
Chinese Indian Indian Other
Black Caribbean Bangladeshi Black Other
Asian Other
Page 1 of 6 July 2011