Surrey Acute Hospitals Pharmacy Undergraduates Summer Placements 2018

APPLICATION FORM TEMPLATE

Applications for work experience in the pharmacy departments at Ashford and St Peter's Hospitals, Frimley Park Hospital and Royal Surrey County Hospital must be completed online.Please use this template application form to prepare your application prior to submission.

Title
Surname
Forename (s)
Contact details for correspondence outside term time / Contact details for correspondence during term time
Address: / Address:
Tel no: / Tel no:
E-mail: / E-mail:
Address to be used for correspondence during summer vacation period: (if known)
Have you any unspent criminal convictions or bind-overs, or any cautions, warnings or reprimands?
Yes/No
If yes, please give details:
Have you at any time received or had pending a criminal conviction, caution, warning, reprimand or bind-over?
Yes/No
If yes, please give details:
Does your name appear on the Protection of Children Act List?
Yes/No
Does your name appear on the Protection of Vulnerable Adults List?
Yes/No
If you are a disabled candidate, do you wish to be interviewed under the guaranteed interview scheme (GIS)?
Yes/No
School of Pharmacy / Current year of course
A Level passes (or equivalent) with grades

REFERENCES

Academic reference / Non-academic reference
Name / Name
Referee's role or job title / Referee's role or job title
Referee's relationship to you / Referee's relationship to you
Address / Address
Tel no / Tel no
E-mail / E-mail

PREVIOUS WORK EXPERIENCE

Please provide brief details of your most recent and relevant work experience here. You will have the option to provide details of 3 work or volunteer experiences in this section. Please provide a brief explanation of role and responsibilities.

Previous work experience 1
Dates
Job title
Employing organisation
Brief summary of role and responsibilities (1000 character limit)
Previous work experience 2
Dates
Job title
Employing organisation
Brief summary of role and responsibilities (1000 character limit)
Previous work experience 3
Dates
Job title
Employing organisation
Brief summary of role and responsibilities (1000 character limit)

SUPPORTING INFORMATION

Please use this section to provide any additional information that you feel is relevant to support your application.

Experience and Knowledge
Briefly describe any previous work experience and knowledge that you feel is relevant to support your application. (2000 character limit)
Skills and Abilities
Briefly describe the skills and abilities you have gained that would be relevant to this post and explain how you would utilise them during your summer placement. (2000 character limit)
Reasons for choosing Surrey Acute Hospitals
Please state the reasons for your interest in working in hospital pharmacy and the Surrey Acute Hospitals. Please explain what you hope to gain from the summer placement. (2000 character limit)
What are your main interests outside work?
Please include why these are important to you and why you enjoy them. (1000 character limit)

Do you require accommodation?

Yes/No

Do you agree that the information provided on this application is accurate?

Yes/No

Please complete the online application form at

DEADLINE FOR APPLICATIONS IS 10th December 2017.

Applications received after this date will not be considered.

Health Education England – Summer student application template