Partnerships for Arts in Healthcare
APPLICATION FORM – COMMISSIONS
1. Commission/s applied for
Please state which commission/s you wish to be considered for:
Name / No.2. Contact details
Name:Address:
Telephone no. ( ) Mobile no. ( )
Fax no. ( )
Email:
Website address:
3. Business information
a)If you are self-employed/freelance, please give your tax reference no.
Tax ref. no.b)Are you VAT registered? Yes [ ]No [ ]
VAT Reg. No.c)If yes, what is your VAT registration no?
d)Do you have Public Liability Insurance? Yes [ ]No [ ]
e)What amount of cover do you have? £
f)Do you have All Risks Insurance? Yes [ ]No [ ]
g)What amount of cover do you have? £
4. Criminal Records Bureau (CRB)
It is Trust policy that artists working unsupervised with children and vulnerable adults are required to be checked by the Criminal Records Bureau. Artists commissioned to design and create artworks may need to have a CRB Disclosure before starting work on the project.
Please indicate whether you have undergone a CRB check. Artists who have not had a CRB Disclosure in the past will not be penalised.
a)Have you had a CRB check? Yes [ ]No [ ]
b)If yes, please give the date of your last check
5. Enclosures
Please make sure that you enclose the following:Tick
10 x still images (slides or jpegs only)[ ]
A list of image titles, media, dimensions, and year made[ ]
Curriculum Vitae[ ]
Expression of interest (500 words max.)[ ]
i.e. why interested, relevant experience, possible idea/s, materials and techniques
for artwork etc.
Description of consultation/involvement of staff, patients, visitors etc.[ ]
(200 words max.) i.e. possible methods, techniques or approaches you might use
SAE for the return of images[ ]
6. Data Protection Act 1998 & Artist Database
Data Protection Act 1998
Southampton University Hospitals NHS Trust will hold your information on a database. It will not be shared with any third party outside the Trust without your consent. You have the right to apply for a copy of your information and to have any inaccuracies corrected.
If you do not wish your information to be included on the database, please tick[ ]
Artist Database
We may be interested in holding your information and slides/jpegs on a database of artists.
If you agree to us holding up to 6 images of your work please tick[ ]
7. Work Permits
To comply with the Asylum and Immigration Act 1996 we are required to take steps to ensure that we do not contract individuals who are not legally entitled to work in the UK.
Please state if you require a Work Permit Yes [ ]No [ ]
8. References
Please give the names and contact details of two people who are able to provide a written professional reference about you and your work. We will approach referees of short listed candidates only.
Referee 1 / Referee 2Name
Address
Telephone no.
9. Declaration
I understand that selection and appointment for this commission, if offered, will be subject to the information given on this form, CV and statements/visuals and that failure to disclose relevant factors will constitute a breach of agreement and render it invalid.
Signed ______Date ______
Please note: The information contained within this document is confidential and only for use by Southampton University Hospitals NHS Trust staff involved in this artwork commission and by artists applying for this project. This document must not be copied, distributed or shared with third parties unless agreed in writing by Partnerships for Arts in Healthcare.
Registered Charity No. 1051543
G:\CGOVDEV\ARTS\Projects\Commissions\Artist App Form 31-08-05.doc