THE CHESTERFIELD DRIVE PRACTICE
Application for Employment
Please remember to fill in ALL SECTIONS in black ink or typescript and remember to sign and date the declaration at the back of the main application form.
The information supplied on this application form will be treated as STRICTLY CONFIDENTIAL
POST DETAILS
Post Applied For: / Ref No:Practice: / q Full time
q Part time No of days/hours……………..
q Job share No of days/hours……………..
PERSONAL DETAILS
Title: Dr q Mr q Mrs q Ms q Miss q Other……… / Telephone (Home):
Mobile Telephone:
Surname:
Previous Name(s) (if applicable): / Telephone (Work):
(Please indicate if we may contact you on this No)
Yes: q No: q
First Names: / E-Mail Address:
Address (in full):
Post Code: / Are you eligible to work in the UK? Proof of eligibility may be requested
Yes: q No: q
National Insurance Number:
Do you hold a valid driving licence for use in the UK? Yes: q No: q
Type – Provisional: q Full: q Other : q Please specify:
Please give details of penalty points (if any) with dates:
As a split site Practice, you may be required to travel between sites. Do you anticipate any difficulty with this? Yes: q No: q
EDUCATION DETAILS
You may be asked to provide evidence of qualifications obtained
Secondary (CSE, GCE, GCSE, RSA, A Levels etc or equivalent)
Examination / Level / Subjects / Grade / Year exam takenFurther and Higher Education (Degree, Diploma, BTEC, City and Guilds, NVQ etc)
From - To / Name & Location of CollegePolytechnic/University / Qualifications gained
(with grade) / Date of
Examination/Award
PROFESSIONAL DETAILS
Professional Qualifications
Professional Qualifications obtained / Date of ExaminationMembership of/Registration with Professional Bodies (ie UKCC, CPSM, GMC)
Name of Professional Body / Level/Type of membership / Reg. Number / Renewal DateOTHER RELEVANT TRAINING AND/OR SHORT COURSES/PERSONAL DEVELOPMENT OR LIFE SKILLS
Examples could include: short courses, skills training, external awards/activities, voluntary work, work experience
EMPLOYMENT DETAILS
Name and address of current/most recent employer: / Job Title:
Current/latest salary and NHS Grade where applicable:
Weekly Hours:
Date Started in post: / Date of Leaving (if relevant):
Notice Required: / Reason for leaving:
Please describe your main duties and responsibilities:
PREVIOUS EMPLOYMENT DETAILS
Name of Previous Employers and nature of business in date order / Position Held with a brief indication of main duties/responsibilities / Dates
From/To / Reasons for
leaving
SUPPORTING INFORMATION/HOW YOU MEET THE SELECTION CRITERIA
It is important that you provide evidence in this section of how you meet the essential and desirable criteria set out in the person specification. Tell us about things you have been responsible for or involved in, what you have achieved and any feedback given. Include examples from paid or unpaid work or other activities you have undertaken in your personal life that are relevant to the job you are applying for. Also include here information about why you want the job and anything else you wish to say.
(Please continue on a separate sheet if necessary)
INTERESTS
Please give details of your hobbies and interests:
REFERENCES
Normally, references will be requested for all candidates invited for interview, unless you ask us not to by ticking the “no” boxes below. This will not affect our decision to invite you for interview. However, references will need to be taken up prior to an offer of employment being made.
Please give the names and addresses of two people who would be willing to supply a reference about you, both of whom must be your two most recent employers (or teacher/tutor where appropriate). The references should be from a person in a position of responsibility relative to yourself, e.g., with management responsibility. Please state in what capacity they know you.
Name:
Organisation:
Address:
Tel No:
E-mail address:
Relationship:
May we contact them if we decide to invite you for interview?
Yes q No q
if “no”, we will contact you for permission before requesting references / Name:
Organisation:
Address:
Tel No:
E-mail address:
Relationship:
May we contact them if we decide to invite you for interview?
Yes q No q
if “no”, we will contact you for permission before requesting references
DECLARATION
I understand that any offer of employment will be subject to the information on this application form and following offer and acceptance of any role I will be required to complete a Declaration of Health form.
I authorise the Practice to make any appropriate checks which may be necessary in relation to posts which require substantial or unsupervised access to children/vulnerable adults. False information, or a failure to supply the details required in this application form could make an offer of employment invalid or lead to termination of employment.
Signature: / Date:
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Ref No:
Job Application Survey Form
Please fill in ALL SECTIONS in black ink, typescript or on screen.
The information supplied on this form will be treated as STRICTLY CONFIDENTIAL and will not be used in any way when assessing your suitability for employment
WE ARE COMMITTED TO PROVIDING EQUALITY OF OPPORTUNITY TO ENSURE THAT ALL JOB APPLICANTS AND EMPLOYEES ARE TREATED FAIRLY IRRESPECTIVE OF SEX, SEXUAL ORIENTATION, PREGNANCY & MATERNITY, AGE, MARITAL STATUS & CIVIL PARTNERSHIP, RELIGION & BELIEF, DISABILITY, RACIAL OR ETHNIC ORIGIN.
This section of the Application form will help us monitor the effects of our policy. It will be separated from the remainder of the application form on receipt and kept confidentially.
PERSONAL DETAILSSurname: / Date of Birth:
First Names: / Age:
Personal Status: Single q Married q Widowed q Divorced q
Other (please specify)
ETHNIC ORIGIN RELIGION
If you feel the choices below do not provide a suitable option, please write how you would describe your ethnic origin)
(a) White (b) Mixed
qBritish qWhite and Black Caribbean
qIrish qWhite and Black African
qAny other White qWhite and Asian
background qAny other mixed background
(c) Asian or Asian British (d) Black or Black British
qIndian q Caribbean
q Pakistani qAfrican
q Bangladeshi qAny other Black background
q Any other Asian background
(e) Chinese or other ethnic group If you have ticked one of the
qChinese ‘Any other ...’ boxes, please
qAny other describe your ethnic origin below
…………………………………… / (If you feel the choices do not provide a suitable option, please write how you would describe your religion)
q Christian q Muslim
q Sikh q Hindu
q Jew q Buddhist
q Other (Please state………………….)
Sex: Maleq Femaleq
Sexual Orientation………………………
MEDICAL/HEALTH HISTORY
New employees will be required to undergo a full medical examination/assessment after offer and acceptance of the job role
DISABILITY
Applications from disabled people are welcome and applicants with a disability or health problem will be given full consideration against the requirements of the post.
Do you have a disability which is relevant to your job application? Yes: q No: q
Are there any special facilities you would like us to provide to help you attend or participate in an interview, or to perform this job? Yes: q No: q
If “yes”, indicate here if you are aware of any adjustments that the Practice could make to enable you apply for or carry out the job? (see guidance notes)
The Practice will make reasonable adjustments to the recruitment and selection process and to the job for successful candidates where the need for these is made known by the applicant/employee.
Definition of Disability
The Disability Discrimination Act 1995 defines disability as follows: A person has a disability if he/she has a physical or mental impairment which has a substantial and long term effect on his/her ability to carry out normal day to day activities.
According to the Act, a disabled person is currently someone who:
· Has a physical or mental impairment;
· The impairment has an adverse and substantial effect on his or her ability to carry out normal day to day activities;
· The effect of the impairment is long term.
Physical or mental impairments are not defined in the Act but examples of conditions covered include:
· Physical impairments: diabetes; epilepsy; multiple sclerosis; cancer, cerebral palsy; heart disease.
· Mental impairments: schizophrenia; dyslexia; bi-polar disorder (manic depression); learning disabilities.
Sensory impairments, such as blindness, having partial sight or hearing loss are also included within “physical and mental impairments”.
DISCLOSURE OF CRIMINAL CONVICTIONS (Rehabilitation of Offenders Act 1974
As the post for which you are applying is concerned with the provision of health services and/or enables you to have access to persons in receipt of health services in the course of your normal duties, you are required to provide details of all criminal convictions against you, including those which for other purposes would be spent under the provisions of the Rehabilitation of Offenders Act 1974.
This information will be completely confidential and will only be considered in relation to your application.
All post-holders working with children or vulnerable adults will be required to complete a Criminal Records check carried out by the Disclosure Barring Service (DBS).
Do you have any criminal convictions? Yes: q No: q
Are there any current criminal proceedings against you? Yes: q No: q
If the answer to either of these questions is YES, please give details :
GENERAL
Are you related to anyone already employed by the Practice Yes: q No: q
If yes, please specify name of person:
How did you become aware of this vacancy?
Job Centre q Local Press q Internet q National press q Other please specify………………………………….
Page 8 of 8 Revised April 2015