Thank you for applying to join the Hospice of St Francis. This application form is designed to help us decide fairly who to interview. Guidance notes on completing the application form:

  • If there is insufficient spaces in any section please continue on a separate sheet.
  • Please complete it honestly and accurately; you will be asked to provide original documents (certificates, right to work documents etc.) at a later stage should you be shortlisted.
  • Decisions about who will be shortlisted for interview will be based on the information given on your application form so ensure you answer all questions fully.
  • For questions that do not apply to you, please put N/A (not applicable) so it is clear you haven’t accidentally forgotten to answer a question. Please do not put “see CV for details” as an answer to a question. You may, however, include a current CV alongside your application form if you think it includes additional information that may be relevant to your application.
  • Please ensure the form is either word processed or written in black or blue ink in block capitals.
  • We are an Equal Opportunities employer. Our aim is to ensure that no job applicant receives less favourable treatment than other applicants because of a protected characteristic due to age, disability, gender reassignment, marriage & civil partnership, pregnancy & maternity, race, religion or belief, sex or sexual orientation.

Position Applied for:
How did you find out about this vacancy?
Hospice website☐ Social Media ☐ Hospice UK ☐ Word of mouth ☐ Local paper ☐ Job board (please specify below) ☐ NHS Jobs ☐ University ☐ Poster ☐ Other (please specify below) ☐
Other:
Have you previously worked for us? Yes☐No☐
If YES, please confirm dates:

Personal Details

Full Name / Title: / Forename(s): / Surname:
Home Address:
Please provide telephone numbers / email addresses we may use to call you about your application
Preferred telephone contact 1:
Preferred telephone contact 2:
Private email:

Employment History

For posts undertaking regulated activities please provide a full employment history including a satisfactory explanation of any gaps in employment. Please list below your present and past employment, beginning with your most recent position.

Employer Name:
Dates of Employment
From: / To:
Current Salary (please include pro rata for part time roles):
Description of the work that you did:
Your reason for leaving: / Length of notice period:
Name and job title of current Line Manager:
Business Address & Telephone number:
Employer Name:
Dates of Employment
From: / To:
Current Salary (please include pro rata for part time roles):
Description of the work that you did:
Your reason for leaving: / Length of notice period:
Name and job title of current Line Manager:
Business Address & Telephone number:

Please continue to detail your employment history belowincluding any other work that you have been involved in; For example: voluntary, freelance, project work etc.

Employers name & nature of business / Date From / Date To / Position Held / Salary / Reason for Leaving
Please give details of any gaps in your employment and/or education history:

Education, Qualifications & Training

Starting with the most recent, please give details of your education, qualifications and training to date.

Professional and vocational qualifications

Name of college
/university / Dates From
/To / Examinations/Qualifications gained / Grade and year obtained

Further/higher education

Name of college
/university / Dates From
/To / Examinations/Qualifications gained / Grade and year obtained

Secondary education

Name of school / Dates From/To / Examinations/Qualifications gained / Grade and year obtained

Other relevant training courses attended (short courses/workplace training)

Course title / Organising body / Duration/year attended

Supporting Statement

Please describe what it is that attracts you to this job and give details of any particular experience, skills and/or qualities that you feel make you suitable for this position and that match the requirements for this post as set out in the person specification. Continue on a separate sheet if necessary.

References

Please provide the names, addresses and occupations of two referees whom we may approach with regard to your application, covering at least 5 years of employment. Referees should be previous line managers/supervisors or HR departments. One referee must be your current or most recent employer.

If you are unable to provide an employer, please give details of a person who knows you in a professional capacity (e.g. education or volunteering).The successful candidate’s references will be sought once a job offer has been made.

Name: / Name:
Position: / Position:
Relationship to applicant: / Relationship to applicant:
Email: / Email:
Business Address: / Business Address:
Telephone: / Telephone:

Right to Work

Are you legally eligible for employment in the UK? Yes  No 
Do you have proof of eligibility to work in the UK? Yes  No 
Note: To comply with The Asylum & Immigration Act 1996, if you are invited to attend an interview, you must bring with you evidence of your eligibility to work in the UK –e.g., a work permit, or a British Passport, a national identity card showing you are a resident of the EEA or Switzerland, a permanent residence card issued by the Home Office, Biometric Immigration Documentation issued by the Home Office, or your passport or travel document endorsed to show you are allowed to stay and work in the UK indefinitely. If you do not possess any of the above documentation please check the eligibility to work requirements for the UK, or contact us directly to find out what is needed. An offer of employment cannot be made unless suitable evidence has been provided to us.

Vehicle Users

Do you have a relevant current driving licence? Yes ☐No ☐
Do you have use of a vehicle? Yes ☐No ☐
Do you have a valid MOT? Yes ☐No☐
Do you have valid insurance? Yes☐No ☐
Please give details of any driving offences currently under endorsement:
Note: If you are invited to attend an interview, and your driving licence is relevant to your application, please bring it with you.

Declaration – Rehabilitation of Offenders

Do you have any unspent criminal convictions, cautions, reprimands or final warnings that are not “protected” as defined by theRehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (amended 2013). For further information visit
Yes☐No ☐
If YES, please provide details below.
If the role you are applying for requires a DBS (please see person specification for the role).
Do you have any spent criminal convictions, cautions, reprimands or final warnings which would not be filtered in line with current guidance?
Yes ☐No ☐
If YES, please provide details below.
Disclosures must be in accordance with the Rehabilitation of Offenders Act 1974 – please seek advice if you are not sure about what has to be disclosed. Please note that the Hospice of St Francis may carry out a Disclosure Barring Service (DBS) check to verify this information.

Professional Membership

Please complete this section if you are required to belong to a professional body in the role you are applying for.

Name of Professional Body: / Expiry Date:
Registration Number: / Revalidation Date:
Have you ever been referred to your professional body? Yes ☐No ☐
If YES please confirm which body and give full details:
Have you ever been disqualified from the practice of a profession or required to practice under specific limitations?
Yes ☐No ☐
Has your employment or contract ever been terminated or suspended - in the UK or abroad - on grounds relating toyour fitness to practice (conduct or performance)?
Yes ☐No ☐
Doctors Only – Please complete this section if you are applying for a medical role
Who is your current/ most recent Designated Body?
Who is your current/ most recent Responsible Officer? (Name, position & contact details)
What is the date of your last and/or next appraisal?
What is the date of your last and/or next revalidation?
Data Protection Act 1998
If I am offered employment, I consent to my information being held and processed by the Hospice of St Francis or its agents in accordance with the Data Protection Act 1998.
If I am not offered employment, I understand that my information will be held by the Hospice of St Francis for 1 year and then securely destroyed if it is no longer required for future vacancies.
Signature: Date:
Declaration
I certify that the information contained in this form and in any related documents is complete and accurate in all respects. Should any changes occur that invalidate any part of this form in the application process I shall notify the Hospice of St Francis. I authorise the Hospice of St Francis to disclose any of this information to its agents, carry out reference checks, and verify the information that I have provided. I understand that should the Hospice of St Francis not be able to arrange or maintain appropriate insurance, or should the facts given by me be inaccurate or untruthful, then the Hospice of St Francis will be entitled to withdraw any offer, or terminate my employment without notice.
I understand that any job offer will be subject to proof of entitlement to work in the UK, a probationary or trial period, the receipt of satisfactory references, and where appropriate, a Disclosure Barring Service and/or a Medical Examination, which are satisfactory to the Hospice of St Francis.
Signature: Date:
Please now send to or to the address in the footer of the page.

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Please complete the Equal Opportunities Monitoring Form on the following pages

Equal Opportunities Monitoring Form

We are an equal opportunities employer. Our aim is to ensure that no job applicant receives less favourable treatment than other applicants because of a protected characteristic due to age, disability, gender reassignment, marriage & civil partnership, pregnancy & maternity, race, religion & belief, sex or sexual orientation.

To help us monitor our performance against our Equal Opportunities Policy, please complete this form and return with the application form above. The information will be treated confidentially and will be used solely for the purpose of monitoring our Equal Opportunities Policy – this information will be detached prior to shortlisting and will not form any part of our interview or appointment decision process. As an equal opportunities employer, it is the Hospice’s policy to appoint the best candidate for any vacancy as defined by a set of objective criteria.

  1. Post Applied for:
  1. How did you find out about this job?
    Please specify the source of publication:
  1. Disability

The following questions are asked in order to assist any person with a disability in order to accommodate individual needs. The answers to any questions on disability will not be used in any way to adversely affect you in any employment decisions that will be made about you, either now or in the future.

Do you consider yourself to have a disability which has lasted or is likely to last at least 12 months?

Yes No

If YES, please provide further information on:

What is the nature of your disability?

What help or support are you currently receiving?

Are there any adjustments to the job role or special equipment that you may require in order to carry out the job role?

  1. How would you describe your ethnic origin?

White

British  IrishAny other White background

Mixed

White and Black CaribbeanWhite and Black AfricanWhite and Asian

Any other mixed background:

Asian or Asian British

Indian Pakistani BangladeshiChinese

Any other Asian background:

Black or Black British

CaribbeanAfricanAny other Black background:

Other ethnic group

Arab Any other:

  1. Sex:

 Male  Female

  1. What is your sexual orientation?

BisexualGay manGay woman/lesbian

Heterosexual/straight Other:

  1. Marital status:

 Married (this includes married but separated)

 Not married(this includes: widowed, legally divorced, co-habiting but not legally married)

 Civil Partnership

  1. Date of birth:______
  1. Religion and belief:

BuddhistChristianHinduJew Muslim

SikhNo ReligionOther Religion or Belief (please state)

The information contained on this form will be kept strictly confidential. It may, however, be necessary to divulge the information to a third party. This will only be to accommodate your application and to seek advice or examine what reasonable adjustments it may be necessary to make.

Data Protection Act 1998

This form may contain information that is classed as Sensitive Personal Data under the Data Protection Act 1998. By providing this information you confirm that the Company may store, process and share this data in accordance with the Company’s Equal Opportunities Policies and related Regulations.