Application for Employment

Position Applied For (required)

Where did you see this vacancy advertised? (required)

Personal Details

Title (required)

First Name (required)

Surname (required)

Current Address (required)

Home Telephone (required)

Mobile Telephone (required)

Email Address (required)

National Insurance Number (required)

Other Details

What is the notice period required in your present post? (required)

Is your present post your sole regular employment? (required)

Are there any restrictions on your right to work in the UK? (required)

If yes, please give details below.

Do you have a full driving licence? (required)

Do you have any current endorsements? (required)

Are there any actual or outstanding issues concerning you which may have implications on your application for employment with St Raphael’s Hospice? (required)

If yes, please give details below.

Professional registrations/memberships (clinical and other professional staff)

Issuing Body

Registration Number

Membership Number and Level

Expiry Date

Any other relevant information.

Education and Training

Secondary Education (please include dates attended and qualifications/grade) (required)

Further or Higher Education (please include dates attended and qualifications/grade) (required)

Other relevant training, professional qualifications or work related skills (e.g. languages) (required)

Are you undertaking any course of study at present? (required)

If yes, please give details below. (required)

Present or Last Employment

Name (required)

Address (required)

Post Title (required)

Date From (required)

Date To (required)

Salary and Benefits (required)

Main Duties and Responsibilities (required)

Previous Employment (most recent first)

Employer 1

Name

Address

Post Held

Date From

Date To

Reason for Leaving

Employer 2

Name

Address

Post Held

Date From

Date To

Reason for Leaving

Employer 3

Name

Address

Post Held

Date From

Date To

Reason for Leaving

Employer 4

Name

Address

Post Held

Date From

Date To

Reason for Leaving

References

Please give the names of people who could provide a reference regarding your suitability for the post for which you are applying. One of these should be your present or most recent employer, who is able to provide a reference on behalf of the employing organisation. School/College leavers should give the name of lecturers/tutors/head teachers.

Reference 1

Name (required)

Address (required)

Telephone Number (required)

Email Address (required)

Type of Reference (required)

May references be taken before interview? (required)

Reference 2

Name (required)

Address (required)

Telephone Number (required)

Email Address (required)

Type of Reference (required)

May references be taken before interview? (required)

Eligibility to Work

Rehabilitation of Offenders Act 1974

In order to protect the public, the post you have applied for is exempt from certain provisions of the Rehabilitation of Offenders Act 1974. You are therefore required to disclose all and any past or pending cautions or convictions, whether spent or otherwise, unless it is either a “protect caution” or a “protected conviction” under the terms of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. All information provided will be kept in the strictest of confidence and only used for the purpose of assessing your suitability for the post you have applied for.

Please specify below details of all and any past or pending cautions or convictions, whether spent to otherwise, except for protected cautions or convictions. If you have no past or pending cautions or convictions, please specify “None”.

Do you have a disclosure certificate from the Disclosure and Barring Service? (required)

Are you a member of the update service? (required)

Please check the box below to signify your consent to St Raphael’s Hospice undertaking a status check, if your application is successful. (required)

I consent to St Raphael’s Hospice undertaking a status check on me

Update Service Reference Number.

DBS Certificate Number

Disabilities

Do you require any special arrangements or adjustments to be made for your interview on account of a disability? (This enables us to comply with our obligations under the Equality Act 2010) (required)

If yes, please give brief details below.

Supporting Statement

Please give any details you feel are relevant in support of your application, including why you are interested in working for St Raphaels Hospice. (required)

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