Return this form to
    Ref. No

    Position applied for

    Title*
    Forename(s)*
    Surname*

    Address*

    Postcode*
    Email*
    N.I. Number*
    Tel Mob*
    Tel Home

    Groups
    Expiry Date

    Details of endorsements:


    (If Yes, please provide details):*



    From Date*
    To Date*
    Name* Job Title* Notice Required*
    Address* Rate of Pay Reason for Leaving*

    Duties*
    Please provide explanation of any gaps if this employment did not immediately follow your previous employment:


    From Date
    To Date
    Name Job Title Notice Required
    Address Rate of Pay Reason for Leaving

    Duties
    Please provide explanation of any gaps if this employment did not immediately follow your previous employment:


    From Date
    To Date
    Name Job Title Notice Required
    Address Rate of Pay Reason for Leaving

    Duties
    Please provide explanation of any gaps if this employment did not immediately follow your previous employment:


    From Date
    To Date
    Name Job Title Notice Required
    Address Rate of Pay Reason for Leaving

    Duties
    Please provide explanation of any gaps if this employment did not immediately follow your previous employment:


    From Date
    To Date
    Name Job Title Notice Required
    Address Rate of Pay Reason for Leaving

    Duties
    Please provide explanation of any gaps if this employment did not immediately follow your previous employment:


    Registration/PIN Number (Nursing):
    GMC Certificate Number (Doctors)

    Please note any other employment that you would continue with if you were to be successful in obtaining this position.


    Name* Email*
    Position* Phone
    Address*
    PostCode*

    May we approach the above prior to interview*?

    Name* Email*
    Position* Phone
    Address*
    PostCode*

    May we approach the above prior to interview?*


    Please detail here your reasons for this application, your main achievements to date and the strengths you would bring
    to this post. Specifically, please detail how your knowledge, skills and experiences meet the requirements of this role (as
    summarised in the person specification).

    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 Exceptions Order 1975 as amended by the Exceptions
    (Amendment) Order 1986, which means that convictions that are spent under the terms of the Rehabilitation of Offenders
    Act 1974 must be disclosed, and will be taken into account in deciding whether to make an appointment. Any information
    will be completely confidential and will be considered only in relation to this application.
    In addition you are required to submit to a Disclosure and Barring check. Any disclosure made by the Disclosure
    and Barring Service will remain strictly confidential.
    Have you ever been convicted in a Court of Law and/or cautioned in respect of any offence? YES/NO (delete as required).
    If YES, please give details.

    Because this position involves employment in a children’s home, it is dependent on the following:
    Your written consent to obtaining a Disclosure and Barring certificate from the Disclosure and Barring
    Service.
    Such disclosure being acceptable to us.
    Proof of identity – birth or marriage certificate (where appropriate) and passport .
    Two satisfactory written references including one from your most recent employer.
    That you will supply a recent photograph of yourself for retention in your records .
    Evidence of physical or mental suitability for your work.
    Documentary evidence of any qualifications relevant for the position .

    I confirm that the above information is complete and correct and that any untrue or misleading information will give
    my employer the right to terminate any employment contract offered.
    Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the
    law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my personnel file during employment and for up to six years thereafter and understand that information will be processed in accordance with the Data Protection Act.
    I agree that should I be successful in this application, I will, if required, apply to the Disclosure & Barring Service for a Disclosure & Barring Certificate. I understand that should I fail to do so, or should the disclosure not be to the satisfaction of the company any offer of employment may be withdrawn or my employment terminated.

    I agree

    Signature or Initials