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Tarporley War Memorial Hospital

Job Application Form

APPLICATION FORM

If you are making a general application to work within the Hospital and you are not responding to an advertised vacancy please state the type of post in which you are interested.

Please complete all sections of this form in black ink.

For the post of:......................................................................................................

Where did you see this post advertised:.........................................................

Closing date:..........................................................................................................

Personal Details:

Ms/Miss/Mrs/Mr/Other:........................................................................................

First Name(s):........................................................................................................

Surname:................................................................................................................

Address:...................................................................................................................

...................................................................................................................................

Postcode:.................................................................................................................

Email:........................................................................................................................

Telephone: Home:.................................................................................................

Work:..................................................................................................

Mobile:................................................................................................
Education and Training (please start with the most recent)

School, College, University etc. Date Commenced
(month & year) Date Left
(Month & Year) Qualifications

Qualifications you are currently studying for:

Qualification:..........................................................................................................

Level/Part/Other:..................................................................................................

Date of Completion:..............................................................................................

Professional Membership:

Organisation & Address
Registration No/Level Expiry/Renewal Date

Details of your current job:

Name of Current Employer:..............................................................................

Address:..................................................................................................................

..................................................................................................................................

Job Title:.................................................................................................................

Date Commenced:................................................................................................

Current Grade/Band:...........................................................................................

Current Salary:......................................................................................................

NHS Pension Scheme Member:.....Yes/No..............(delete as applicable).

Period of Notice Required:..................................................................................

Reason for Leaving:..............................................................................................

Please give a brief summary of the main duties of your current job:

...................................................................................................................................

Details of your previous employment: (most recent first)

Employers Name & Address
Job Title
Grade/Band Date Commenced Date of Leaving Reason for Leaving

References:

Please give the name and address of two referees from your two most recent employers, one of whom must be your current or most recent line manager. Please indicate if you have changed your name since your last contact with each referee.

Referee 1 Referee 2

Name:........................................... Name:.................................

Title:.............................................. Title:...............................................

Address:........................................ Address:.........................................

........................................................ ..........................................................

Postcode:...................................... Postcode:.......................................

Email:............................................. Email:.............................................

Tel No:........................................... Tel No:...........................................

Contact prior to interview Y/N Contact prior to interview Y/N

If you are shortlisted for interview, we will ask both your referees to send a reference prior to your interview. If you do not wish one or both to be contacted at that stage please indicate Y/N in the box containing their details.

Note:

Please bring a recent passport size photograph with you if selected for interview.

Additional Information:

Please write a statement to support your application, covering the skills and knowledge you have which are relevant to the job you are applying for. Continue on a separate sheet if necessary. You may attach a CV to your application form if you wish to do so, but you must ensure that all questions on the form have been answered.

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..................................................................................................................................

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Work Permits and Visas:

Do you need a work permit to work in the United Kingdom? Yes/No

If you currently hold a work permit or visa please give details including its type and expiry date:

...................................................................................................................................

Declarations by the Applicant:

Have you been bound over, convicted or charged with a criminal offence, received a police caution, final warning or reprimand, or are you currently the subject of any police investigation whether in the UK or any other country?

Yes/No - delete as applicable

If yes, please provide full details including the approximate date, the authority and the country concerned.

...................................................................................................................................

Have you been disqualified from the practice of a profession required to practice it subject to specified limitations, or are you currently the subject of fitness to practice investigations, or proceedings by a regulatory body in the UK or any other country?

Yes/No - delete as applicable

If yes please provide full details including the approximate date, the name and address of the regulatory body and the country concerned.

...................................................................................................................................

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I confirm that I have not inappropriately canvassed any member of staff within the Hospital or any member of the Board of the Trust with regard to this application.

I understand that the appointment, if offered, is subject to health clearance and, if appropriate, confirmation of qualifications and/or Professional Registration together with a satisfactory search with the Criminal Records Bureau.

I certify that the information given on this form is correct and understand that any misleading information or deliberate omissions will be regarded as ground for withdrawal of an offer, or if appointed, subsequent disciplinary action which could lead to dismissal.

I accept that records will be kept of this application and if I am successful records will be kept during and after my appointment.

Signed:...................................................................................

Date:......................................................................................

The information in this application form will be held in strictest confidence and in accordance with the Data Protection Act.

Tarporley War Memorial Hospital Trust

Equal Opportunities in Employment
To enable us to monitor the effective of the Hospital's Equal Opportunities and Anti-Discrimination Policies, it would be very helpful if you will complete the form and return this questionnaire with your application form. Please note that the questionnaire will be separated on receipt so that it forms no part of the initial short listing process. The information you provide will only be used for monitoring purposes.

Application for the Post of:.................................................................................

Name of Applicant:.................................................................................... Male/Female

Are you currently employed by this Hospital? Yes/No

I would describe my ethnic origin as:

White:

(a) British
(b) Irish
(c) Other

Mixed:

(d) White & Black Caribbean
(e) White & Black African
(f) White & Asian
(g) Any Other Mixed Background

Asian or Asian British:

(h) Indian
(j) Pakistani
(k) Bangladeshi
(l) Any Other Asian Background

Black or British Black:

(m) Caribbean
(n) African
(p) Any Other Black Background

Other Ethnic Groups: