Job Application Form Application for Employment Confidential Application for Employment for St John's Hospice in LANCASTER. 1 Job Details2 Your Details3 Education / Training4 Current Employer5 Supporting Information6 Reference 17 Reference 28 Declaration Name of position you wish to apply for.*Name of the position you are interested inHours Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Mr/Miss/Mrs/Ms/Dr First Last Email* Enter Email Confirm Email Address* Street Address Address Line 2 City County Post code Home PhoneMobileWork NumberIs it ok to contact you on this number? Yes, you can contact me at work Do you have a full UK driving licence?* Yes No Do you have use of a vehicle during work hours* Yes No General Education*Please provide full details in the sections below. Click on the plus icon to create additional spaces. FromToSchool/College/UniversitySubject(s) TakenLevelGrade Professional/technical/specialised training and qualifications (held or being studied)FromToInstitute/Professional BodyQualificatio/Training detailsGrade (if applicable) Professional RegistrationMembership ofRenewal date(s)Registration Number Current Employment/most recent employment (reference always required)*Name of companyEmployer's Address Street Address Address Line 2 City County Postcode Position Held*SalaryDate Appointed* Date Left (if applicable) Employer's BusinessGive a description of current duties and responsibilities*Reason for leavingPeriod of NoticePrevious employmentName of companyEmployer's Address Street Address Address Line 2 City County Postcode Position HeldSalaryDate Appointed Date Left (if applicable) Employer's BusinessGive a description of current duties and responsibilitiesReason for leavingEmployment HistoryPlease list with most recent first, and account for any breaksName and Address of EmployerPosition HeldFromTo Supporting Information*In the space below please tell us how you match the requirements of the person specification for the job (you can view a person specification for this vacancy on our website). This should include relevant skills, knowledge, experience, voluntary activities and training etc. If relevant to the post for which you are applying you should include details about research experience, publications or poster presentation, clinical care (knowledge and skills) and clinical audits. Have you any criminal convictions or bind overs, or any cautions, warnings or reprimands?(spent, current or pending)*Policy statement for the Recruitment of Ex-offenders applies. Yes (If yes please give details below) No Please give detailsYour offer of employment will be subject to a satisfactory disclosure from the Disclosure and Barring Service. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment.Professional Body Action - Are you aware of any investigations or actions pending, or have any ever been taken, against you by a professional body?* Yes (If yes please give details below) No Please give details Please give two referees who have consented to be approached for a reference on your behalf. One must be your current line manager or HR Department. Relatives are not acceptable as referees.Name* First Last OccupationAddress* Street Address Address Line 2 City County Postcode Phone NumberEmail Address May we contact this referee before interview?* Yes No May we contact this referee if successful?* Yes No Capacity in which referee knows you:* Name* First Last OccupationAddress* Street Address Address Line 2 City County Postcode Phone NumberEmail Address May we contact this referee before interview?* Yes No May we contact this referee if successful?* Yes No Capacity in which referee knows you:* Declaration: I confirm that the information provided in my application is correct and understand that misleading statements, deliberation omissions or inclusion of incorrect details may be sufficient to disqualify me from appointment.* Yes, I confirm Declaration: I understand that any appointment will be subject to relevant pre-employment checks which meet with regulatory requirements and the hospice’s satisfaction. If I am successfully appointed I give my consent for the hospice to contact the referees provided to obtain a reference.* Yes, I confirm The information given in your application will be held securely, in accordance with the Data Protection Act 1998, not shared with any other individuals or organisations, and will only be used for the purpose of processing your application for employment. In line with our procedures if you are unsuccessful in your application we will delete all your data after 6 months. Unfortunately St. John’s Hospice is unable to respond to all applicants individually. If you have not had a response to your application within three weeks of the closing date please assume that on this occasion your application has been unsuccessful. Once you complete our monitoring form you will receive a confirmation to say we have received your application form. NameThis field is for validation purposes and should be left unchanged.
