Job application (The Conifers) - Central England Healthcare

Application for the post of:

Personal details

National Insurance number*

Title*

Surname*

First name(s)*

Previous name (if applicable)

Home address*

Street Address Address Line 2 Town/ City County Post code

Telephone number*

Date of birth*

Place of birth*

Do you require a work permit to be employed in this country?*

Yes
No

Expiry date of existing permit*

Number of children*

Ages of children

Other dependents*

Name of next of kin*

Relationship*

Address of next of kin*

Street Address Address Line 2 Town/ City County Post code

Home telephone number*

Mobile number*

Have you ever worked for or applied to The Conifers before?*

Yes
No

Please provide details*

Details of absence from work (excluding holidays) over the last 12 months

Number of days absence*

Number of episodes*

Do you have a current full driving licence?*

Yes
No

Do you own a car?*

Yes
No

How many miles do you live away from The Conifers?*

Are you related to any present or former employees of The Conifers?*

Yes
No

Please provide details*

Education and qualifications

List*

Date	College/ Hospital/ University	Qualification & Grade

Professional qualifications

List*

Dates	College/Hospital/University	Qualification & Grade

If applicable: UKCC PIN

Renewal date

Qualifications still to be taken*

Date	College/ Hospital/ University	Subject & Level

Please specify the exam date and level with the subject and School/ College/ University

Current or most recent post

Employer*

Job title*

Starting date*

Do you have a leaving date or are you still employed*

I have a leaving date
I'm still employed

Leaving Date*

Reason for leaving*

Current Salary/Wage or Finishing Pay*

(This information must be correct as it will be verified)

Employment history

Please include all jobs since leaving education. State most recent position first and include gaps in employment and the reason (eg unemployment, bring up family).*

Start date	Leave date	Employer	Job title	Reason for leaving

Hobbies

Please give details of any special interests/hobbies including voluntary work*

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

Name*

Position*

Organisation*

Address*

Street Address Address Line 2 Town/ City County Postcode

Telephone number*

Is this your current employer?*

Yes
No

Are they related to you?*

Yes
No

2nd referrer

Name

Position

Organisation

Address

Street Address Address Line 2 Town/ City County Postcode

Telephone number

Is this your current employer?

Yes
No

Are they related to you?

Yes
No

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.

Please give details of any convictions with dates

Declaration*

I certify that the information given on this form is correct to the best of my knowledge. I understand that any misleading statement or deliberate omission may be sufficient grounds for refusal or termination of employment. This appointment is subject to a satisfactory medical examination and the completion of a supplementary medical questionnaire. I understand that any engagement is subject to the receipt of satisfactory references and DBS check.

Signature

Date of signature

Do you consider you have a disability?*

Yes
No

Please indicate the nature of your disability

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.

Would you describe your ethnic origin as:*

Please specify

Are you:*

Male
Female

Please indicate your age in the ranges below:*

Application form