Hospice Staff Application Form

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Join the team and make a Difference

www.wsbhospices.co.uk

APPLICATION FOR EMPLOYMENT

Please fill in this Application Form, and note that questions marked with an asterisk * are mandatory and therefore must be answered.

HR Department, Woking & Sam Beare Hospices Denton Way, Goldsworth Park, Woking, Surrey GU21 3LG

For Office Use Only

Details entered in this part of the form will be held in the HR department of the recruiting organisation. For details on how your data will be kept and stored please read our Privacy Notice www.wsbhospices.co.uk/about-us/information-governance/hr-volunteer-data/

Job Title*

Department*

Personal Details

Surname/Family Name*

First Names*

Title*

UK National Insurance No*

Postcode*

Address*

Home Telephone*

Country*

Mobile Telephone*

Work Telephone

Email Address*

May we contact you at work?*

Yes

Date of Birth

MM slash DD slash YYYY

Gender*

Male

Female

I do not wish to disclose this

Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National?*

Yes

Do you have leave to enter/remain and the right to work in the United Kingdom (UK)?*

Yes

If your right to remain in the UK requires a visa or permit please supply details, including permit/via number, validity and expiry date

Preferred Employment Type*

Full Time

Part Time

Bank work

If relevant to your role do you have a valid driving licence for the UK?

Yes

If relevant to your role do you have access to a vehicle which can be used for work purposes?

Yes

Equality Act 2010 (Disability Discrimination)

If you tell us that you have a disability we can make reasonable adjustments to where you work and your work arrangements and at interview.

Do you consider yourself to have a disability?

Yes

I do not wish to disclose this information

Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

Physical Impairment

Sensory Impairment

Mental Health Condition

Learning Disability/Difficulty

Long-standing illness

Other

If you have a disability do you require any specific arrangements to enable you to attend for interview?

Yes

If yes, please supply details below

Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions to employers after the rehabilitation period set by the Court has elapsed and the convictions become ‘spent’. During the rehabilitation period, convictions are referred to as ‘unspent’ convictions and must be declared to employers. Before you can be considered for appointment with Woking & Sam Beare Hospices we need to be satisfied about your character and suitability. Woking & Sam Beare Hospices aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation or age. Woking & Sam Beare Hospices undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.

Have you any unspent criminal convictions or any cautions, warnings or reprimands?*

Yes

If yes, please give details

If you are applying for a post involving access to persons in receipt of health services, your 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.

Personal Relationships

If you are related to, or have a relationship with a current employee of Woking & Sam Beare Hospices please state the employee’s name and your relationship*

Education & Professional Qualifications

Include in this section all the relevant qualifications. Please also indicate subjects currently being studied.

Education Details

Subject/Qualification

Place of Study

Grade/result

Year

Training Courses Attended

Training Courses

Course Title

Training Provider

Duration

Date Completed

Employment History

Current Employer

Please record below the details of your current employment

Employer Name

Address

Type of Business

Telephone

Job Title

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Notice Period

Salary

Reporting to (job title)

Reason for leaving (if applicable)

Description of your duties and responsibilities

Previous Employment

Please record below the details of your previous employment beginning with the most recent first giving full career history details. Please use additional sheets of paper if required. Please explain any gaps in employment in the ‘Supporting Information’ section below.

Previous Employer 1

Employer Name

Address

Job Title

Grade

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Reason for Leaving

Description of your duties and responsibilities

Previous Employer 2

Employer Name

Address

Job Title

Grade

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Reason for Leaving

Description of your duties and responsibilities

Previous Employer 3

Employer Name

Address

Job Title

Grade

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Reason for Leaving

Description of your duties and responsibilities

Previous Employer 4

Employer Name

Address

Job Title

Grade

From Date

To Date

Reason for Leaving

Description of your duties and responsibilities

We require a full employment history therefore if there insufficient room above please attach additional sheet/s if necessary or attach as copy of your CV.

Supporting Information

In this section please give your reasons for applying for this post and additional information which shows how you match the person specification for the job (you will have been sent this document with the application form). This can 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 audit.

Supporting information (Please continue on additional sheets if necessary).

References

Please give the names of the people who have agreed to supply references. For all positions you must provide two references. If you are, or have been employed, these should be your two most recent employers. These may include your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. If you are a student please provide contact details of a teacher at your school, college or university. Please note that personal references such as friends and relatives are not acceptable. For all posts written references obtained must cover the preceding three years of employment.

Surname/Family name*

First Name

Title

Job Title

Address*

Post Code*

Country*

Telephone

Fax

Email*

Relationship*

Can the referee be contacted prior to interview?*

Yes

Surname/Family name*

First Name

Title

Job Title /Company Name

Address*

Post Code*

Country*

Telephone

Fax

Email*

Relationship*

Can the referee be contacted prior to interview?*

Yes

Where did you see this vacancy advertised?

Hospice Website

Search Engine

Other Website

National Newspaper

Local Newspaper

Jobcentre Plus

Radio

Other

Current employee of WSBH

The information in this form is true and complete. I agree that any deliberate omissions, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This applies equally to any medical questionnaire/forms I may complete.

I agree to the above declaration

Signature

Name

Date

MM slash DD slash YYYY

Join the team and make a Difference

APPLICATION FOR EMPLOYMENT

Personal Details

Equality Act 2010 (Disability Discrimination)

Rehabilitation of Offenders Act 1974

Personal Relationships

Education & Professional Qualifications

Training Courses Attended

Employment History

Current Employer

Previous Employment

Supporting Information

References

Help us make a difference

Woking Hospice

In need of care and support?

In need of treatment?

Hospice Staff Application Form

Join the team and make a Difference

APPLICATION FOR EMPLOYMENT

Personal Details

Equality Act 2010 (Disability Discrimination)

Rehabilitation of Offenders Act 1974

Personal Relationships

Education & Professional Qualifications

Training Courses Attended

Employment History

Current Employer

Previous Employment

Supporting Information

References

Help us make a difference

Staying in touch

Call our reception: 01483 881750