Job Application FormJob Application Form Step 1 of 250%Details about you and the job you are applying forPost applied for:*Please state where you heard about the vacancy?*Weldmar websiteWessex FMLocal Press (please state)Social MediaIndeedWord of mouthNHS JobsWeldmar Shops / NoticeboardsOtherIf 'other' please let us know how you found out about this vacancyName* MrMrsMissMsDrProf.Rev. Prefix First Middle Surname Known as Address* Street Address Address Line 2 Town/City County Postcode Home Telephone Number*Day Time Telephone Number*Mobile Telephone Number*Email Address* Qualifications/Grade and School/College/University attendedExample: GCSE Maths / A* / Example College / July 2015Membership of Professional BodiesPlease complete this section if it is applicable for the role you are applying forProfessional Body*Not ApplicableNursing and Midwifery Council (NMC)British Medical Association (BMA)Health and Care Professions Council (HCPC)Chartered Institute of People and Development (CIPD)Other (please state)If other, please stateQualification:PIN Number / Membership NumberExpiry Date DD MM YYYYRevalidation Date DD MM YYYYTransportDriving Licence* Yes NoOwn Transport* Yes NoDo you have a clean driving licence?* Yes NoIf you answered no, please provide more details belowCurrent or most recent employmentName of current or most recent employer*Current Job Title*Address of current or most recent employer* Street Address Address Line 2 Town/City County Postcode Email of current or most recent employer* Phone*Date started* DD MM YYYYPeriod of notice*Current salary*Hours worked per week*Brief description of duties and responsibilities:*Employment HistoryPlease complete your employment history below. This must include any employment over the last 20 yearsName and address of previous employer 1Job titleEmployed from DD MM YYYYEmployed to DD MM YYYYReason for leavingName and address of previous employer 2Job titleEmployed from DD MM YYYYEmployed to DD MM YYYYReason for leavingName and address of previous employer 3Job titleEmployed from DD MM YYYYEmployed to DD MM YYYYReason for leavingName and address of previous employer 4Job titleEmployed from DD MM YYYYEmployed to DD MM YYYYReason for leavingAny other employmentPlease provide details of any other employment within the last 20 years, which is not specified aboveGaps in EmploymentPlease explain any gaps in employment history during the last 20 yearsApplying for this postPlease use this section below to tell us why you are applying for this post and refer to any relevant skills, knowledge, experience and achievements to support your application providing evidence against the job description and person specificationPlease describe why you are applying for this post*Rehabilitation of Offenders Act 1974*Have you any convictions or are currently the subject of police proceedings in this or any country? Yes NoProtection of Vulnerable Adults/Protection of Children Act 1999*Are you or have you ever been subject of any fitness to practice proceedings by a UK or overseas licensing or regulatory body? Yes NoReferencesPlease give the names of two people who are able to provide references relating to your work experience and your suitability for the post applied for. One referee should be your current or most recent employer. If you have not been in paid employment please give the name(s) of someone who can confirm the information provided on this form for example school/college tutorContact Name and Position of Reference 1*Name and Address of Reference 1* Street Address Address Line 2 Town/City County Postcode Phone*Email address of Reference 1* Please tick this box if you would rather we did not contact this Reference prior to interview Please do not contact this Reference prior to an interviewContact Name and Position of Reference 2*Name and Address of Reference 2* Street Address Address Line 2 Town/City County Postcode Phone*Email address of Reference 2* Please tick this box if you would rather we did not contact this Reference prior to interview Please do not contact this Reference prior to an interviewPlease note:If successful you will be required to complete a pre-employment Occupational Health questionnaire and a Disclosure and Barring Service check. Any offer of employment will be subject to satisfactory reports from each of these.Do you require a work permit?* Yes NoThe organisation does not have a policy of obtaining permits on behalf of applicants.General Data Protection Regulation (GDPR)It is important for us to collect and retain personal information about you, such as your contact and employment details, so we are able to communicate with you throughout the application process, and to support you as reasonably and effectively as possible. We will maintain your data as set out in our Privacy Notice for Job Applicants which can be viewed by visiting www.weld-hospice.org.uk/jobs or by contacting the People Services DepartmentI understand that by clicking next, I confirm that, to the best of my knowledge, the information given in this application is accurate and complete.Clicking next will take you to the Equal Opportunities Monitoring Form. You can return to this page should you need to before clicking submit.Equal Opportunities Monitoring FormWeldmar Hospicecare recognises, values and respects that each person is unique. The Charity is against any form of discrimination covered by the Equality Act 2010, ie. age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation. The Charity is aware that discrimination stops people being treated equally. The Charity is committed to being fair and equal in all areas of delivering a service. The information in this form will be recorded solely for monitoring the profile of Weldmar Hospicecare.Name* MrMrsMissMsDrProf.Rev. Prefix First Last Known As Postcode* Postcode Date of Birth* DD MM YYYYWhat gender are you?* Male Female Transgender I would prefer not to sayIf you prefer to use your own term, please specify here:Equality Act 2010Please select the option which best describes your sexual orientation* Heterosexual or straight Homosexual Gay man & Gay woman/lesbian Bisexual Asexual I would prefer not to answerWhat is your faith, culture or belief?* Atheism Buddism Christianity Hinduism Islam Jainism Judaism Sikhism None I do not wish to disclose my religion/belief OtherIf other, please stateHow would you describe your Ethnic Group?* White British White Irish Black / Black British Caribbean Black / Black British African Chinese White and Black Caribbean White and Black African White and Asian Indian Pakistani Bangladeshi Other ethnic group Other White background Other Black background Other mixed heritage Other Asian background I would prefer not to answerIf you selected other...If you selected any of the following, please state - Other White, Black or Asian background, other ethnic group or other mixed heritageDo you consider yourself to have a disability?* Yes No I do not wish to disclose this informationPlease state the type of impairment which applies to you. If you tell us that you have a disability we can make reasonable adjustments to where you work, your work arrangements and at interview. Physical Impairment Sensory Impairment Mental Health Problem Learning Disability/Difficulty Long-standing illness OtherDeclaration*By ticking this box, I confirm that the information on this form is true and complete. I agree that any deliberate omission, falsification or misrepresentation will be grounds for rejecting my application. I agreeDate of completion* DD MM YYYY
