Involve Yorkshire & Humber

Application Form – Do not submit a CV. Your application will only be considered if you have completed all sections of the application form

Please only reply to

This page will be detached before short-listing
and will only be seen by the interview panel after interviews are completed.

Application for post of / Health Network Director
Forename:
Family Name:
Address:
Postcode:
Telephone:
e-mail:
REFERENCES Please give details of two people to whom reference may be made, one of these must be your most recent employer. If you are shortlisted the references will be taken up before interview unless you request otherwise.
1. Name / 2. Name
Address
Postcode / Address
Postcode
Email: / Email:
Tel. No / Tel. No
Capacity in which known to you… / Capacity in which known to you…
Current Salary: £
May we contact before interview / May we contact before interview
YES / NO / YES / NO

YOUR SIGNATURE –
I declare that the information I have given in this application is true and accurate. I understand that providing misleading or false information will disqualify me from appointment OR, if appointed, may result in my dismissal. The information on this form will be processed in accordance with the Data Protection Act, and we may check the information collected with third parties. If you are employed by the Regional Forum this information will form the basis of your employment record, otherwise it will be destroyed after 6 months.

XDATE

(signed hard copy required on day of interview if not before)

Equal Opportunities Monitoring Form

Please complete this form in black ink or typescript

EQUAL OPPORTUNITIES

Involve Yorkshire & Humber has an Equal Opportunities policy which aims to eliminate discrimination in employment. Our policy aims to eliminate direct and indirect discrimination on grounds of sex, sexual orientation, marital status, colour, race, nationality, ethnic or national origin, creed, religion, age or disability.

To enable Involve to assess this policy we have a set up a system of monitoring job applications. The questions on the following pages will be used for this purpose and only used to provide statistics for monitoring purposes. All information provided will be treated in confidence and will not be seen by the interview panel. We would be grateful if you could complete these questions to assist us with our equal opportunities monitoring. Please note if you decide not to fill out the form, it will have no bearing on your application. Thank you for your assistance.

ETHNIC ORIGIN

I would describe my ethnic origin as follows: ( tick appropriate box)

Asian or Asian British
 Indian
 Pakistani
 Bangladeshi
 Any other Asian background
Please write below
……………..…………………… / Black or Black British
Caribbean
African
Any other Black background
Please write below
…………………………………
Mixed or Mixed British
 White & Black Caribbean
 White & Black African
 White & Asian
 Any other mixed background
Please write below
……………..…………………… / White
British
Irish
Any other White background
Please write below
……………..……………………
Chinese, British Chinese or any other Ethnic Group
 Chinese
 Any other Ethnic background
Please write below
……………..……………………

PERSONAL INFORMATION

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?
Yes/No (if yes please provide details)
If you are successful in your application, would you require a work permit prior to taking up employment?
Yes/No
Do you have a National Insurance Number? Yes/No
If no, do you have evidence of your entitlement to live and work in the UK?
Yes/No

The above pages will be detached before short-listing
and will only be seen by the interview panel after interviews are completed.

1. Using your current and past work, please demonstrate how you meet the ‘EXPERIENCE AND QUALIFICATIONS’ element of the Person Specification (point 1) and the Job Description

For this section use only the space provided. Please do NOT continue on an additional sheet.

2. Using your current and past work, please demonstrate how you meet the ‘KNOWLEDGE AND UNDERSTANDING’ element of the Person Specification (point 2) and the Job Description

For this section use only the space provided. Please do NOT continue on an additional sheet.

3. Using your current and past work, please demonstrate how you meet the ‘SKILLS AND APTITUDE’ element of the Person Specification (point 3) and the Job Description

For this section use only the space provided. Please do NOT continue on an additional sheet.

EMPLOYMENT: Please indicate any paid employment you may have had starting with your most recent employer.
Employer’s name & postal address / Post Held; including key duties & responsibilities / Duration / Reason for Leaving
You may continue this section on a separate sheet if necessary
Please provide information on any gaps in your employment / education history:
VOLUNTARY/COMMUNITY WORK. Please indicate any voluntary activities you may have undertaken.
Organisation name & address / Post held/activity / Duration
You may continue this section on a separate sheet if necessary
EDUCATION AND TRAINING Please indicate any education and/or training you have undertaken, adding where appropriate any qualifications you have obtained
Institute; Name & Address / Course followed / Qualification gained / Course duration
You may continue this section on a separate sheet if necessary

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