Job Application form Section A: Application for Employment Post details Application for the post of: Department: Closing date: Personal Title: Please select... Mr Mrs Ms Miss Other First name: Last name: Address: Town/City: County: Postcode: Phone: Mobile: Email: National insurance no: Date of birth: Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) national? Yes No Please tick the category that relates to your current immigration status.This status will be subject to checking before interview. Indefinite leave to remain/enter Highly Skilled Migrant Programme Tier 1 Work Permit Tier 2 Dependent / Spouse Visa Working Holiday Visa / Tier 5 Youth Mobility Clinical Attachment Visa Refugee Visitor Post Grad Doctors and Dentists Tier 5 Temporary Workers Students Do you have a legal right to work in the UK? Yes No Do you have a work permit? Yes No Please state details: References Please give the names and addresses of TWO referees (not relatives) whom we may contact. One of these should be your current or last employer if you have been employed recently. We will not contact your current employer without your permission.Please note: references will be requested following interview. First referee Reference: Business Character Name: Job title: Address: Postcode: Phone: Email: Second referee Reference: Business Character Name: Job title: Address: Postcode: Phone: Email: Rehabilitation of Offenders Act 1974 Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198'. Yes No Please give details: Section B: Application for Employment Education and training Type: Name: From: January February March April May June July August September October November December 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 To: January February March April May June July August September October November December 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Qualifications gained with grades: Date gained: January February March April May June July August September October November December 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Membership to professional bodies Include in this section any relevant professional registrations or memberships. If you are applying for a post that requires professional registration, you are required to provide the following information. Body: Membership No: Expiry date:(optional) Employment History - Current or most recent employer Current/Most Recent Post Held: Name of Current/Most Recent Employer: Address of Current/Most Recent Employer: Postcode: Job title: Date started: Salary: Notice required: Reason for leaving (if applicable): Full employment history, explaining any gaps in employment Post held: Name of employer: Address of employer: Postcode: From: To: Reason for leaving (if applicable): Supporting evidence In support of your application, please give evidence detailing how you meet the requirements of the job and the knowledge, skills and abilities as detailed in the Person Specification. You should also give relevant examples to support any assertions. Please restrict your answer to no more than 2000 words Section C: Equal Opportunities Form Pendleside Hospice is required to collect Equal Opportunities information. This information is for monitoring purposes only and will help the organisation analyse the profile and make up of applicants and appointees to jobs. This section is not made available to the panel at any point during the process. The Hospice recognises and actively promotes the benefits of a diverse workforce and is committed to treating all employees with dignity and respect regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. We therefore welcome applications from all sections of the community. I would describe my ethnic origin as follows: Please Select Bangladeshi Indian Pakistani Any other Asian background White & Asian White & Black African White & Black Caribbean Any other mixed background Chinese Any other ethnic group I do not wish to disclose this African Caribbean Any other Black background British Irish Any other White background Please indicate your gender: Please Select Male Female Transgender I do not wish to disclose this Please select the option which best suits your sexuality: Please Select Heterosexual Lesbian Gay Bisexual Other I do not wish to disclose this Please indicate your religion or belief: Please Select Atheism Buddhism Christianity Islam Jainism Sikhism Judaism Hinduism Other I do not wish to disclose this The Equality Act 2010 protects disabled people – including those with long term health conditions, learning disabilities and so called “hidden” disabilities such as dyslexia. If you feel that you have a disability we will make reasonable adjustments to ensure that the selection process is fair and equitable. Please contact us to arrange any support which will help you in the selection process. Do you consider yourself to have a disability? Yes No If applicable, 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 these categories apply, please mark “Other” . Physical impairment Sensory impairment Mental health problem Learning disability / difficulty Long-standing illness Other Declaration The information in this form (Parts A, B & C) is true and complete. I agree that any deliberate omission, fabrication or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This applies to any medical questionnaire/forms I may complete. Where did you see this vacancy advertised? Hospice Website Hospice Facebook page Indeed Jobs Local Newspaper Hospice UK Website NHS Jobs Hospice Internal Notice Board Other Please give details: Spam protection: 9G8X24XRTPNNZK Type or copy & paste the code you see on the left side.