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Application form

  • Personal details

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • Details of absence from work (excluding holidays) over the last 12 months
  • Education and qualifications

  • DateCollege/ Hospital/ UniversityQualification & Grade 
  • Professional qualifications

  • DatesCollege/Hospital/UniversityQualification & Grade 
  • Date Format: MM slash DD slash YYYY
  • DateCollege/ Hospital/ UniversitySubject & Level 
    Please specify the exam date and level with the subject and School/ College/ University
  • Current or most recent post

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • (This information must be correct as it will be verified)
  • Employment history

  • Start dateLeave dateEmployerJob titleReason for leaving 
  • Hobbies

  • References

    Please give below the names and addresses of two referees who can provide relevant information regarding your experience and qualifications for this appointment. One should be your present/last employer. Please note that if an employment offer is made to you your referees will be approached without further contact with you for permission.
  • 1st referrer
  • 2nd referrer
  • Rehabilitation of offenders act

    Because of the nature of the work for which you are applying, the post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975. Applicants are not entitled to withhold information about convictions which for any other purposes are spent under the provision of the Act and in the event of employment failure to disclose convictions could result in summary dismissal. Any information given will be confidential and considered only in relation to an application for positions to which this order applies. Note that false declarations may be reported to the Police.
  • Date Format: DD slash MM slash YYYY
  • Equal Opportunities Monitoring Form

  • The information supplied on this form will be used in total confidence and in accordance with current Data Protection legislation. It will help us to ensure that The Haven properly monitors and conforms with its policies relating to the equality of opportunity. Information will be used for monitoring and for no other purpose. Our committed aim is to allow our staff to develop their skills and realise their maximum potential as individuals without any wish on the part of The Haven to limit their opportunities. Please tick the relevant box or boxes.

Striving
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Contact

Conifers Nursing Home
16 -18 Johns Lane
Great Wyrley
Walsall
WS6 6BY

Tel: 01922 415 473
Fax: 01922 411 388
Email: office@conifersnursinghome.co.uk

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