Royal College Abcdefg of Physicians

Faculty of Pharmaceutical Medicine

3rd Floor, 30 Furnival St, London, EC4A 1JQ

Tel: +44 (0)20 7831 7662 Fax: +44 (0)20 7831 3513

Registered Charity Number: 1130573

APPLICATION FOR EMPLOYMENT

POSITION APPLIED FOR / Revalidation Support Administrator (12-month contract)
Title (Mr/Mrs/Miss/Ms/Other)
Surname:
Forename/s:
CONTACT DETAILS
Address for Correspondence:
Post Code:
Email: / Mobile Tel No:
Tel No. (Day): / Tel No. (Evening):
AVAILABILITY
Notice Period / Able to Start / Existing Holiday Requests
PRESENT OR MOST RECENT EMPLOYMENT
Employer's name and address and type of business / Dates / Position held and nature of responsibility / Reason for leaving/wishing to leave
(please indicate if full or part time) / From / To
Basic Annual Salary / Total Annual Salary including Benefits
(please give full details)
PREVIOUS POSTS
(Please list in order starting with most recent and give explanation of any gaps in employment)
Continue on separate sheet if required
Dates (month/year)
(Please indicate any part-time appointments) / Employer's name and address and type of business / Position held, nature of responsibility, salary upon leaving / Reason for leaving
From / To
EDUCATION AND QUALIFICATIONS
(In chronological order)
Dates / Education institutions attended and courses taken / Qualifications obtained
From / To
Other courses taken and / or qualifications obtained with dates:
YOUR SKILLS & EXPERIENCE
Use this space to explain clearly how your skills and experience meet the requirements of the post as set out in the Person Specification and Job Description. Please give examples to demonstrate how you meet these requirements. You may attach a separate document if you wish.

Continue on a separate sheet if required
EMPLOYMENT ELIGIBILITY
Are you free to remain and to take up employment in the United KingdomYES/NO
REFEREES
Please give details of at least two referees, not related to you, who can be approached. One of the referees should be your present or most recent employer. References will only be taken up if a conditional offer of employment is accepted.
PRESENT OR MOST RECENT EMPLOYER / SECOND REFERENCE
1. Name:
Position: / 2. Name:
Position:
Address: / Address:
Tel No: / Tel No:
Fax No: / Fax No:
Email: / Email:

Where did you see the advertisement?

Faculty website ______

Jobs.ac.uk______

Other – please specify______

DECLARATION
This section must be completed. Shortlisted candidates who submitted their applications electronically will be asked to provide an original counter signature.
I declare that the information I have given in support of my application is, to the best of my knowledge and belief, true and complete. I understand that if it is subsequently discovered that any statement is false or misleading, or that I have withheld relevant information, my application may be disqualified or, if I have already been appointed, I may be dismissed. I understand that any initial offer of employment that may be received would be conditional upon the outcome of a health evaluation and the receipt of two satisfactory references.
Signature: ...... …………………………………….
Name (Please Print):……………………………………………………………………………………...
Date: ...... ……………………………………..
Data Protection Act 1998
All information held about you will be held securely and will be used for the purposes of recruitment to this position or for monitoring purposes. Data relating to unsuccessful applications will be kept for a maximum of twelve months from the closing date.
I give permission that my personal data, including that which is defined as sensitive personal data under the Act, is used for the purposes stated above.
Signed: …………………………………………………… Date: ………………………………….

Please return completed and signed application forms to:

Recruitment

Faculty of Pharmaceutical Medicine

3rd Floor, 30 Furnival St

London, EC4A 1JQ

Please mark your envelope ‘Private and Confidential’.

CV’s in isolation will not be accepted

The deadline for receipt of applications is 5pm on Wednesday 23 January 2013

FACULTY OF PHARMACEUTICAL MEDICINE

EQUAL OPPORTUNITIES MONITORING FORM

The Faculty of Pharmaceutical is committed to promoting equal opportunity and eliminating discrimination in all areas of its activity.

Equal opportunities monitoring is undertaken and information obtained may be analysed to assess compliance with the policy. Information will be held confidentially and used for monitoring purposes only.

Any reports will be anonymised to ensure that individuals cannot be identified.

Your Name / Your Date of Birth

Please complete all 3 sections below:

1. What is your ethnic background? (Choose one section from A-E, and then tick the appropriate box)

AWhite

BritishIrish

Other, please specify :

BMixed

White & Black Caribbean White & Black African White & Asian

Other, please specify :

CAsian or Asian British

IndianPakistani Bangladeshi

Other, please specify:

DBlack or Black British

Caribbean African

Other, please specify :

EChinese or any other ethnic background

Chinese

Any other background, please specify:

2. What is your gender?(please tick one box below)

Male Female

3. Do you have a disability? Defined as ‘a physical, sensory or mental impairment which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities’ (Disability Discrimination Act 1995) (please tick one box below)

Yes No

Please return this form to the Faculty Office with your Application Form.

Upon receipt, this form will be separated from your application form.

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