The Poplars Medical Centre

APPLICATION FORM

THIS FORM MAY BE COMPLETED IN TYPE OR BLACK INK USING ADDITIONAL SHEETS AS NECESSARY AND SENT TO:
THE PRACTICE MANAGER, THE POPLARS MEDICAL CENTRE, 202 PARTINGTON LANE, SWINTON, MANCHESTER. M27 0NA / Candidate No:
(For office use only)
Reference No : / Post :
Medical Administrator / Hours of Work :
delete as appropriate / Closing Date :

PERSONAL INFORMATION

Surname : / Home Address :
Post Code :
Forename(s) :
Title : / Telephone No. Work :Ext :
Home :
Date of Birth :
National Insurance No : / How did you become aware of this vacancy? eg. jobs bulletin, local press, etc.
Jobs in Health
Other (please state the title of publication)
Do you require a work permit? : Yes No

REGISTRATION

(Nursing, midwifery and professional posts)
Registration/PIN No: / Date obtained : / Expiry date :

EDUCATION/PROFESSIONAL QUALIFICATION

General education/further education/professional or trade qualifications/relevant training courses / Level/part / Year
obtained / Specify the name of the establishment you attended or how you obtained the qualification.
Qualifications currently being studied for : / Level/part / Exam Date / Specify place of study.

PRESENT/MOST RECENT EMPLOYMENT

Name and address of present/most recent employer : / Present Post :
Date Appointed :
Notice period required :
Salary :

DUTIES OF PRESENT/MOST RECENT POST

PREVIOUS EMPLOYMENT

Please give details of past work over the last 10 years and all previous National Health Service experience. This can be paid work, voluntary work or work at home. Your most recent employment first please.
Employer / Post held / From / To / Reason for Leaving
Please give below a concise account of your experience relevant to the post for which you are applying and any other information that you wish to give in support of your application.

YOUR HEALTH

On how many days and how many occasions over the past 12 months have you been unfit to work, whether you have been in employment or not?
Number of Days : / Number of Occasions :
Please give details of any serious illness you suffer from or have suffered from which could affect your capacity to work.
(The Practice reserves the right to verify information with your current or previous employer and any offer will be subject to satisfactory medical examination.)

REFERENCES

Please give in BLOCK LETTERS the names and addresses of two people (relatives must not be used) who have agreed to act as a referee for you. A reference will be sought wherever possible from an employer when you are short listed and also from a previous employer if you have been in your present employment for 18 months or less.

1Name : / 2Name :
Job Title : / Job Title :
Address :
Postcode : / Address :
Postcode :
Telephone No. / Telephone No.
Capacity in which reference is given : / Capacity in which reference is given :
If you are known to your referee by a name other than the one used on the front of this form, please give the name here :
IF YOU ARE SHORTLISTED , PLEASE INDICATE WHETHER REFERENCES MAY BE SOUGHT PRIOR TO INTERVIEW
Yes No

REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of 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 (Exemptions) Order 1975. Applicants are therefore not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act. In the event of employment, any failure to disclose such convictions could result in dismissal.
Any information given will be confidential and will be considered only in relation to an application for positions to which the Order applies. Please supply any information on separate sheet.
I declare that the information contained in this form or attached to it is true and complete. I understand that if it is subsequently discovered that any statement is false or misleading the Practice has the right to dismiss me from my employment. I also understand that canvassing will disqualify and that the appointment will be subject to a satisfactory medical screening which may involve a medical examination.
Date: / Signature of Applicant :