The Crown

Medical Practice

12 Crown Avenue

Inverness IV2 3NF

Tel: 01463 214450

crownmedicalpractice.co.uk

APPLICATION FOR EMPLOYMENT

Please type or write using black ink

Post Title Salaried GP
Closing Date

Personal Details

Surname
Forename(s)
Address
Post code
E-mail / Tel home
Tel work / Mobile

Information about your education and training

School, college, university / From / To / Qualifications / Grades / Dates of qualifications

Qualifications you are currently studying for

Qualification / Level/Part/Other details / Date you expect to complete

Professional Registration

Issuing Body / Registration No / Level/Part / Expiry/Renewal date

Present/Last Employer

Name and Address of Employer
Nature of business (If not NHS) / Position Held
Grade / Salary
From / To
Notice Required
Reasons for leaving
Please summarise your main duties

Previous Employment

Give details of all your previous jobs stating with the most recent.

Please put an asterisk (*) next to any agency posts

Employers name & address / Job Title / Grade/Salary / From / To / Reason for leaving

Supporting Information

Please write a statement to support your application, covering the skills and knowledge you have which are relevant to the job you are applying for. Continue on a separate sheet if necessary. If you wish, you may attach a CV to your application form but you must ensure that all questions on the form have been answered.

Please continue on a separate sheet if necessary

Are there any facilities you require to enable you to attend or perform well at interview?

References

Give the names and addresses of two people who can provide an assessment of your suitability for this post. If you are currently employed, or have been employed you are asked to give your current or most recent employer. If you are a student, please give an academic referee.

Name
Address
Post Code / Job Title
Relationship to you (e.g. line manager, tutor etc)
Telephone no
Fax no
E-mail
Contact before interview / Yes □ / No □
Name
Address
Post Code / Job Title
Relationship to you (e.g. line manager, tutor etc)
Telephone no
Fax no
E-mail
Contact before interview / Yes □ / No □

References from family or friends are NOT acceptable.

Work Permits & Visas

Do you need a work permit to work in the United Kingdom?(please tick) / Yes □ / No □ / I do not know □
If you currently hold a work permit or visa, please give details including its type and expiry date:

General Information

How did you hear about this vacancy?
(If from an advertisement please state which publication)
If shortlisted, dates unavailable for interview

Declarations

Have you been bound over, convicted or charged with a criminal offence, received a
Police caution, final warning or reprimand, or are you currently the subject of any police
Investigation whether in the UK or any other country? (please tick) / Yes
□ / No
□
If yes, please provide full details, including the approximate date, the authority and the country concerned.
Note: many posts in the NHS, especially those involving patient contact, are exempt from the Rehabilitation of Offenders Act 1974. You must therefore declare all prosecutions or convictions, including those considered “spent” under this Act.
Have you been disqualified from the practice of a profession, required to practise it subject to specified limitations, or are you currently the subject of fitness to practise investigations or proceedings by a regulatory body in the UK or any other country? (please tick)
If yes please provide full details including the approximate date, the name and address of the regulatory body and the country concerned.
NOTE: Any information you supply in respect of the above two questions will be treated as confidential and will not necessarily prevent you from being considered for the post for which you have applied. / Yes
□ / No
□
I understand that the appointment, if offered, is subject to health clearance and, if appropriate, confirmation of qualifications and/or professional registration, and Criminal Records Disclosure (if applicable)
I certify that the information given on this form is correct and understand that any misleading information or deliberate omissions will be regarded as grounds for withdrawal of an offer or, if appointed, subsequent disciplinary action which could lead to dismissal.
I accept that records will be kept of this application and if I am successful records will be kept during and after my appointment.
Signature / Date

Please ensure your completed application form reaches the following address.

Anne MacKenzie

The Crown

Medical Practice

12 Crown Avenue

Inverness IV2 3NF

Tel: 01463 214450

OR

ConfidentialPage 101/01/2019