Post applied for                    

Department:                          

Based at                                

PERSONAL DETAILS

Surname (Block capitals) Title:
If you have been known by a different name, please indicate previous name/s  Click here if  under l8yrs or over 65yrs of age
Forenames
Address for correspondence Home telephone
Work telephone
Post Code
E-mail address
How did you hear of this vacancy? if in publication, please state which
Do you require a work permit ? if yes give details
Please give dates on which you will NOT available for interview  If selected when could you start?

Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act, 1974, by virtue of the Rehabilitation of Offenders Act (Exceptions) Order 1973. Applicants are, therefore, not entitled to withhold information about convictions which, for other purposes, are 'spent' under the provisions of the Act, and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by the Trust. Any information given will be completely confidential and will be considered only in relation to posts to which the order applies.

Do you have any convictions to disclose?  - Please give details

REFERENCES

Please give the names and addresses of two referees. These should include your present employer (last employer if currently unemployed). Personal referees such as friends or relatives are not acceptable.

Name Name
Address Address
Post Code Post Code
Telephone Number Telephone Number
Email Address Email Address
Relationship Relationship

If you are invited for interview, referees will be contacted. 

DO YOU WISH US TO DO THIS, PLEASE CLICK HERE . 

Offers of employment will not be made without references being received.

EDUCATION AND QUALIFICATIONS

Secondary Education

NAME OF SCHOOL/COLLEGE DATES FROM DATES TO SUBJECT QUALIFICATIONS GAINED GRADE/CLASS DATE

FURTHER EDUCATION (including Refresher Courses and Vocational Trailing)

NAME OF COLLEGE/UNIVERSITY DATES FROM DATES TO SUBJECT QUALIFICATIONS GAINED GRADE / CLASS DATE

EDUCATION/TRAINING CURRENTLY ONGOING

NAME OF COLLEGE SUBJECT LEVEL EXPECTED DATE OF COMPLETION

PROFESSIONAL REGISTRATION DETAILS

NAME OF PROFESSIONAL BODY MEMBERSHIP GRADE &/OR REGISTRATION No. & P.I.N. No. HOW GAINED e.g. Part-time, Full-time EXPIRY DATE

EMPLOYMENT HISTORY

NAME & ADDRESS OF PRESENT OR MOST RECENT EMPLOYER AND NATURE OF BUSINESS POSITION HELD, GRADE IF APPLICABLE AND SUMMARY OF JOB/DUTIES FROM Mth/Yr TO Mth/Yr SALARY (inc. all allowances) REASON FOR LEAVING

Health Record (Over last twelve months):

Number of days unable to work due to sickness? How many different occasions?

Comments:

NAMES OF PREVIOUS EMPLOYERS/ ORGANISATIONS INVOLVED WITH, NATURE OF BUSINESS. (STARTING WITH MOST RECENT) POSITIONS HELD WITH SUMMARY OF DUTIES FROM Mth/Yr TO Mth/Yr REASON FOR LEAVING

SUPPORTING INFORMATION

Please tell us why you have applied for this post and give a brief summary of your relevant experience and skills.

If you have made any other applications to St. George's Healthcare during the past twelve months, please indicate department, job title and approximate date:

EQUAL OPPORTUNITIES IN EMPLOYMENT MONITORING INFORMATION

St. George's Healthcare operates an equal opportunities policy, which requires fair and equal treatment of all job applicants.

We wish to ensure that all employees are recruited, trained and promoted on the basis of their ability, the requirements of the job and the need to maintain a highly effective and efficient patient care service.

To help check whether this policy is working we record the ethnic origin and sex of all applicants and wether applicants are in any way disabled. Please fill in the following sections to help us do this.

This information will in no way affect your application for employment.

Please tick the appropriate box

           

 

How would you describe your ethnic origin? (These classifications are those recommended by the Commission for Racial Equality).

Please tick the appropriate box

            )

           

In accordance with the provisions of the 1996 Disability Discrimination Act, please let us know if you consider yourself to have a disability you would like to tell us about.

              if yes -  (Please give details )

 

DECLARATION

I hereby declare that the information given in my application is correct to the best of my knowledge.

Clicking submit will send this application, if you are invited to interview you will be required to sign a hardcopy of this application form.

NB:  Canvassing members/officers of St. George's Healthcare, directly or indirectly, providing false information with regard to this application, shall disqualify the candidate from such appointment, or if discovered after appointment, will lead to dismissal.