DR. S. Pill
DR. A. Byrne
DR. M. Hoghton
DR. S. Bunce / CLEVEDON RIVERSIDE GROUP
CLEVEDON MEDICAL CENTRE
OLD STREET
CLEVEDON
BS21 6DG / Dr. S. Mitchell
Dr. A. Brown
Dr. D. Liberman
TEL: 01275 335666
PRACTICE No. L81040

Application for Employment

(use block capitals in black ink)

Job Title of post for which you are applying:MEDICAL RECEPTIONIST (FULL TIME POST)

PERSONAL DETAILS

Surname:First Names:
Mr/Mrs/Miss/Ms or other title:
Address:
Telephone Number (including STD code)
Home:
Business:
Mobile:
Postcode:Email:
Do you hold a full drivers licence? Yes / NoDoes your licence have any penalty points? Yes / No
(If yes give details)
Notice required by present employer:
Do you require a work permit to be employed in the United kingdom?Yes / No

MISCELLANEOUS

Are you a patient of this practice? (if yes, we may ask you to register with another practice if your application is successful) Yes / No
Where did you hear about this vacancy?

REFERENCES

Give the name and addresses (and telephone numbers if possible) of two referees. The first should be your present or most recent employer. Ideally the second should be the most recent previous employer.
1.0
Telephone number:
2.0
Telephone number:
May we approach them prior to interview?
1.0Yes / No2.0Yes / No
(Referees will only be contacted if you have been requested to attend an interview and have indicated yes. Should you indicate No, we will contact referees should your application be successful. References are confidential and we will not, therefore, enter into any discussion with candidates with regard to their contents.
REHABILITATION OF OFFENDERS ACT 1974
Under the above Act most sentences awarded by a Court for criminal offences may be regarded as spent and disregarded, for most purposes, after a specific period of time and need not them be disclosed. However, if the appointment for which you have applied is one to which the Rehabilitation of Offenders Act (Exceptions) Orders apply, you are required to declare any criminal convictions and enquiries and checks may be made in that respect.
It is your responsibility to distinguish between those convictions, which require to be declared, and those, which do not.
Have you ever been convicted in a court of law? Yes / No
If Yes Please provide full details below:
Data Protection Act 1998: Any information supplied may be held on paper or computer files and therefore falls within the provision of this act.

EDUCATION, QUALIFICATIONS AND TRAINING

Please give details of your places of education, training & qualifications obtained & associated dates:

EMPLOYMENT:

Please provide details of your present and all previous employment (paid or unpaid), giving name and address of employer, job title, dates of employment, current/last salary/pay, main responsibilities and reason for leaving:

SUPPORTING STATEMENT

Please use this space, and/or a separate sheet to describe how your experience, skills and knowledge relate to the job description and the essential and desirable criteria on the person specification. Please provide examples if appropriate.

ADDITIONAL INFORMATION

Please provide any further information which you think may assist us in considering your application:

INTERESTS

Please provide details of your main interests and hobbies:

DECLARATION

I declare that, to the best of my knowledge and belief, the information given in this application is correct:
Signed:Date:

Please return your completed application form in an envelope marked PRIVATE & CONFIDENTIALto:

Mel Parker,

Assistant Practice Manager

Clevedon Riverside Group

Clevedon Medical Centre

Old Street

Clevedon

North Somerset

BS21 6DG