"*" indicates required fields Step 1 of 10 10% Join the team and make a Differencewww.wsbhospices.co.uk APPLICATION FOR EMPLOYMENTPlease 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 OnlyDetails 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 DetailsSurname/Family Name* First Names* Title* UK National Insurance No* Postcode* Address* Home Telephone*Country* Mobile Telephone*Work TelephoneEmail Address* May we contact you at work?* Yes No 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 No Do you have leave to enter/remain and the right to work in the United Kingdom (UK)?* Yes No 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 No If relevant to your role do you have access to a vehicle which can be used for work purposes? Yes No 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 No 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 No If yes, please supply details below Rehabilitation of Offenders Act 1974The 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 No 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 RelationshipsIf 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 QualificationsInclude in this section all the relevant qualifications. Please also indicate subjects currently being studied.Education DetailsSubject/QualificationPlace of StudyGrade/resultYear Add RemoveTraining Courses AttendedTraining CoursesCourse TitleTraining ProviderDurationDate Completed Add Remove Employment HistoryCurrent EmployerPlease record below the details of your current employmentEmployer Name Address Type of Business TelephoneJob 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 EmploymentPlease 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 1Employer 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 2Employer 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 3Employer 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 4Employer 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 InformationIn 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). ReferencesPlease 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* TelephoneFax Email* Relationship* Can the referee be contacted prior to interview?* Yes No Surname/Family name* First Name Title Job Title /Company Name Address* Post Code* Country* TelephoneFaxEmail* Relationship* Can the referee be contacted prior to interview?* Yes No 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 declarationSignature Name Date MM slash DD slash YYYY