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Please complete the application form below. For assistance please see the Guidance For Applicants.

St Catherine's Hospice is committed to equality of opportunity in both employment and service delivery. A policy statement and monitoring form are enclosed with this application form. Managers involved in the shortlisting process will make decisions based solely on the information you provided on this application form.

Application for the post of:

Ref number:

Closing date:

Forename(s):

Surname:

Email address:

Home telephone number:

Alternative number:

Address

Town

Postcode

EDUCATION

School

Subject and Grade e.g. English C

Date attained

College/Sixth Form

Subject and Grade

Date attained

University

Subject and Grade

Date attained

PROFESSIONAL QUALIFICATIONS

Organisation

Level of Qualification/Membership

Date

By examination

Yes No

Grade

Qualification 2

Organisation

Level of Qualification/Membership

Date

By examination

Yes No

Grade

Qualification 3

Organisation

Level of Qualification/Membership

Date

By examination

Yes No

Grade

PROFESSIONAL MEMBERSHIPS

Membership Body(e.g. NMC, GMC)

Registration type

Registration number

Renewal date

Membership 2

Membership Body(e.g. NMC, GMC)

Registration type

Registration number

Renewal date

Membership 3

Membership Body(e.g. NMC, GMC)

Registration type

Registration number

Renewal date

CURRENT OR MOST RECENT EMPLOYMENT

Job title:

Employer:

Salary:

Date appointed:

Notice required / date left:

Reason for leaving:

Describe the main duties and responsibilities of your present/most recent post:

PREVIOUS EMPLOYMENT (most recent first)

Job title:

Brief description of duties:

Reason for leaving:

EMPLOYER/ ADDRESS

Date from:

Date to:

Employer 2

Job title:

Brief description of duties:

Reason for leaving:

EMPLOYER/ ADDRESS

Date from:

Date to:

Employer 3

Job title:

Brief description of duties:

Reason for leaving:

EMPLOYER/ ADDRESS

Date from:

Date to:

SUPPORTING STATEMENT

Drawing upon your experience, knowledge, skills and abilities, explain how you fulfill the requirements set out in the person specification. Experience may also have been gained through paid or voluntary work or in the home.

LEISURE INTERESTS

Please tell us a little about what you enjoy doing when you are not working.

REFERENCES

Please give the name and address of three Referees who can comment on your skills, experience and personality. The Referees must be able to verify your employment history (or college/school where appropriate) over the past 24 months.

Current/most recent employer

Name:

Position:

Telephone number:

Address:

Postcode

May we approach this referee prior to the interview?

Yes No

Referee 2

Name:

Position:

Telephone number:

Address:

Postcode

May we approach this referee prior to the interview?

Yes No

Referee 3

Name:

Position:

Telephone number:

Address:

Postcode

May we approach this referee prior to the interview?

Yes No

HEALTH STATEMENT

Sickness absence may be discussed at interview. Successful candidates will be required to complete a declaration of health form and undergo an occupational health examination.
Please state number of occasions and number of days absent due to sickness over the last 2 years.

Number of days:

Number of occasions:

The Hospice does not discriminate against applicants with disabilities, please therefore assist us by completing the section below:

Do you consider you have a health problem or disability as defined under the Disability Discrimination Act 1995, which is relevant to your job application?

Yes No

Please give details, including any adjustments to the workplace or post to enable you to perform in the post:

REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 2(2) of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants are, therefore, not entitled to withhold information about convictions including those which for other purposes are 'spent' under the provisions of the Act, and in the event of employment any failure to disclose such convictions could result in dismissal or disciplinary action by the Hospice. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the Order applies, but it is essential that you declare any convictions received in any court of law.

Are you currently the subject of any police investigation and/or prosecution, in the UK or any other country?

Yes No

Have you ever been convicted of any criminal offence required by law to be disclosed, received a police caution in the UK, or a criminal conviction in any other country?

Yes No

If you have answered yes to any of the above, please give further details:

ASYLUM AND IMMIGRATION ACT 1996

If successful in your application for this post, you will be required to provide evidence of your entitlement to live and work in this country. Evidence of your National Insurance Number could include a P45, pay slip, P60, NI card or a letter issued by one of the Government bodies. Alternatively, a UK European Union or Republic of Ireland birth certificate or passport showing permission to live and work within the UK.

Are you in a position to provide this evidence?

Yes No

Do you require a work permit to work in this country

Yes No

If you are an overseas national, please give details of visa/permit currently held.

DECLARATION

Can you confirm that to the best of your knowledge there are no medical reasons which would prevent you from undertaking the duties of the post?

Yes No

Can you confirm that you are not the subject of any investigation or proceedings by any body having regulatory functions in relation to health/social care professionals including such regulatory body in another country?

Yes No

Can you confirm that you have never been disqualified from the practice of a profession or required to practise it subject to specific limitations following a fitness to practice investigation by a regulatory body, in the UK or another country?

Yes No

I understand that:-

the appointment, if offered, will be subject to information given on this form being correct;
providing false information with regard to this application shall disqualify me from such appointment, or in the future lead to a termination of employment.
any appointment is subject to the receipt of satisfactory references, a satisfactory occupational health clearance, Criminal Records Bureau Disclosure (if applicable) and successful completion of a three month probation period.