PERSONAL DETAILS

Title:

Surname:

Previous Name  (If appropriate)

First Names:

Address (In full)

Postcode

Telephone (Home):

Mobile:

Telephone (Work):

Email:

Are we able to ring you at work:                  YES  [  ]      NO  [  ]

Are you a British Citizen or

European Economic Area National              YES [  ]     NO   [   ]

Do you require a work permit                       YES [   ]    NO   [   ]

Do you have Permit Free Status                  YES [   ]    NO   [   ]

If `no` please give details of your status of entry to the UK.

Do you hold a full current valid driving licence   YES [  ]     NO   [   ]

Do you have the ability to be mobile                  YES [  ]     NO   [   ]

if the duties of the post require it:

National Insurance Number :

EDUCATIONAL DETAILS  (You may be asked to provide evidence of qualifications obtained)

Name & Location of School/College/

University

Date From

Date To

Qualification gained

Grade

Date obtained

PROFESSIONAL DETAILS

Professional Qualifications Obtained

Date of Examination

Membership of / Registration with Professional Bodies

Name of Professional Body

Level/Type of Registration

Reg. Number

Renewal Date

OTHER RELEVANT  TRAINING AND/OR SHORT COURSES/PERSONAL DEVELOPMENT OR LIFE SKILLS

PRESENT/MOST CURRENT EMPLOYMENT

Name and address of current/most recent employer:

Job Title:

Current/latest salary and NHS Grade where applicable:

Weekly hours:

Date Started in post:

Date of leaving (if relevant)

Notice Required:

Reason for leaving (if relevant)

Please describe your main duties and responsibilities

PREVIOUS EMPLOYMENT INFORMATION

Employer/Nature of Business

Position Held

(Specialty/Grade if applicable)

From

To

Reason for leaving

SUPPORTING INFORMATION 

Please give a concise account of any relevant experience and further details in support of your application.   If you have not held recent regular employment please include details of any activities which may help with your application.    Please continue on separate sheet if necessary.

REFERENCES

Please state names and contact details of two referees who would be willing to supply a reference about you.   References must be provided by your present and next most recent employer, or place of study.  (If not currently employed you should provide details of last two employers).  For health professionals references should be supplied by the clinical line manager.  Normally references will be requested for all candidates invited for interview unless you ask us not to by ticking the “no” box below.    This will not affect our decision to invite you for interview – however references will be taken up prior to an offer of employment

Name:

Name:

Organisation:

Organisation:

Address:

Address:

Tel No:

Tel No:

Relationship:

Relationship:

May we approach prior to interview

Yes [  ]     No   [   ]

May we approach prior to interview

Yes   [  ]       No   [   ]

DISCLOSURE OF CRIMINAL CONVICTIONS (Rehabilitation of Offenders)

As the post for which you are applying is concerned with provision of health services and/or enables you to have access to persons in receipt of health services in the course of your normal duties, you are required to provide details of all criminal convictions against you, including those which for other purposes could be spent under the provisions of the Rehabilitation of Offenders Act 1974.     This information will be completely confidential and will only be considered in relation to your application.    All postholders working with children or vulnerable adults will be required to complete a Criminal Records check carried out by Criminal Records Bureau.

Do you have any criminal convictions                                                   Yes   [   ]    No  [   ]

Are there any current criminal proceedings against you                       Yes   [   ]    No  [   ]

Have you ever received a police caution, reprimand or final warning   Yes   [   ]    No  [   ]

If you have answered Yes to any of these questions please give details (including dates) on separate sheet)

SIGNED

DATE

DECLARATION

I understand that any offer of employment will be subject to the information on this application form and the Declaration of Health form being complete and correct.    False information, or a failure to supply the details required in this application form could make an offer of employment invalid or lead to termination of employment.    I understand that information about my application will be recorded and processed on computer in order to progress and monitor appointment.    I consent to the recording and processing of personal data in this way in accordance with the Data Protection Act 1998

Signed:

Date:

PLEASE RETURN COMPLETED FORM TO:

SUFFOLK WEST PCT

For work in the community and at Newmarket Hospital

Mary Hughes

NHS Professionals

Stanton Health Centre

12 The Chase

Stanton

BURY ST EDMUNDS

Suffolk       IP31 2XA

TEL:  01359 251422

WEST SUFFOLK HOSPITAL

For work at West Suffolk Hospital

Karen Giles

NHS Professionals

West Suffolk Hospitals NHS Trust

Hardwick Lane

BURY ST EDMUNDS

Suffolk

IP33 2QS

Tel:  01284  713837 or 01284 713000 bleep 477

PERSONAL DETAILS

Surname

Date of Birth

First Names

Age

Personal Status:      Single       [   ]      Married     [   ]

                                 Widowed  [   ]      Divorced   [   ]

Other (please specify)      ..........................................

Sex:

Male         [   ]

Female     [   ]

Sexual Orientation

How did you hear about NHS Professionals

ETHNIC ORIGIN  - I would describe my ethnic origin as (please tick a box)

WHITE

MIXED

ASIAN OR ASIAN BRITISH

BLACK OR BLACK BRITISH

OTHER ETHNIC GROUP

British            [   ]

Irish                [   ]

Any other

white

background    [   ]

White &

Black
Caribbean       [   ]

White &

Black African   [   ]

White &

Asian               [   ]

Any other

mixed

background      [   ]

Indian             [   ]

Pakistani        [   ]

Bangladeshi   [   ]

Any other

Asian

background    [   ]

Caribbean     [   ]

African          [   ]

Any other

black

background    [   ]

Chinese            [   ]

Any other

Ethnic

Group              [   ]

RELIGION

If you feel the choices do not provide a suitable option please write how you would describe your religion below:

Buddhist   [   ]

Christian  [   ]

Hindu      [  ]

Jew     [   ]

Muslim    [   ]

Sikh       [  ]

Other please state

DISABILITY

Do you have a health problem or disability which is relevant to your job application    YES   [   ]  NO   [   ]

If yes indicate here if you are aware of any adjustments that NHS Professionals could make to enable you to apply for or to carry out the job?