St David's Hospice Care | Job Application form

Personal Details

Title

First name

Surname

Middle name

Preferred name

Previous last name

Full address

Email address

Home contact number

Mobile number

Right to work in the UK (Asylum & Immigration Act 1996)

You will be required to produce original documents to prove your eligibility at the interview/assessment stage and bring photocopies of them. Please don't forget to bring them with you, otherwise we will not be able to progress your application any further.

Particular requirements

Do you have any particular requirements if you were invited to the interview/assessment?

Yes

No

If yes, please give details

References

Offers of employment are subject to two satisfactory references, one of which must be from your present or most recent employer. Please provide details below of your referees. Please note references will not be sought until an offer of employment has been made. If you are unable to provide two employment references please provide an academic reference or a volunteering reference.

Reference 1

Full name

Job title

Company

Address

Postcode

Tel

Email

Work relationship to you

Your previous job title (if employer reference)

Your employment date (if employer reference)

From (dd/mm/yyyy)

To (dd/mm/yyyy)

Reference 2

Full name

Job title

Company

Address

Postcode

Tel

Email

Work relationship to you

Your previous job title (if employer reference)

Your employment date (if employer reference)

From (dd/mm/yyyy)

To (dd/mm/yyyy)

Employment or volunteering history

Please start with the most recent period of employment

Date from (dd/mm/yyyy)

To (dd/mm/yyyy)

Name of employer

Address

Postcode

Position held

Reason for leaving

Previous employer/position

Date from (dd/mm/yyyy)

To (dd/mm/yyyy)

Name of employer

Address

Postcode

Position held

Reason for leaving

Previous employer/position

Date from (dd/mm/yyyy)

To (dd/mm/yyyy)

Name of employer

Address

Postcode

Position held

Reason for leaving

Previous employer/position

Date from (dd/mm/yyyy)

To (dd/mm/yyyy)

Name of employer

Address

Postcode

Position held

Reason for leaving

Previous employer/position

Date from (dd/mm/yyyy)

To (dd/mm/yyyy)

Name of employer

Address

Postcode

Position held

Reason for leaving

Please account for any periods of unemployment (if applicable)

Are any of your relatives employed by St. David's Hospice or St. Anne's?

Yes

No

If YES please give their name and relationship to you

Name

Relationship

Education

Please give details of the Schools/Colleges/Universities you attended

Full name

Town/City

+ Add more fields

Qualifications

Please include all academic, technical and professional qualifications, plus dates awarded.

Qualification title

Qualification type

Grade/Level

+ Add more fields

Please supply details of any further training courses attended that are relevant to your application

Please detail any professional bodies you are a member of

Professional body

Membership type

Membership number

Driving licence details

Only complete if applicable to position

Do you hold a full UK driving licence?

Yes

No

N/A

Licence number

Expiry date

Do you have any endorsements? If yes please give details

Date

Offence code

Offence

Rehabilitation of offenders

Have you been convicted of a criminal offence which is not spent under the Rehabilitation of Offenders Act 1974?

Yes

No

If yes, please provide details

Availability

Please show your maximum range of availability where applicable to role

Sunday - Available hours - Start time

Sunday - Available hours - End time

Monday - Available hours - Start time

Monday - Available hours - End time

Tuesday - Available hours - Start time

Tuesday - Available hours - End time

Wednesday - Available hours - Start time

Wednesday - Available hours - End time

Thursday - Available hours - Start time

Thursday - Available hours - End time

Friday - Available hours - Start time

Friday - Available hours - End time

Saturday - Available hours - Start time

Saturday - Available hours - End time

For part-time roles, what is the minimum and maximum number of hours you are willing to work per week?

Min

Max

Please give details of any holidays booked in the next six months

Please detail any days/times you are unable to attend interview

Additional information

Please use the space below for any additional information you wish to provide in support of your application

Applicant's declaration

The information on this form will be held and used by St David’s Hospice in accordance with the provisions of the Data Protection Act 1998 and all relevant subsequent legislation. This information will be held and processed for the purpose of personnel/payroll administration and statistical analysis.

I certify that the information given on this form is correct and acknowledge that any false statement renders me liable to summary dismissal.

Tick to agree

Diversity monitoring form

The information we collect is stored confidentially and securely. Data Legislation protects you and your data. All personal information is stored confidentially and can only be accessed by authorised persons in the Human Resources office. Once collected, this information can show us who is joining and leaving and ensures that all staff are treated fairly. Completing this information will help us to deliver against our diversity commitments and contribute to an inclusive working environment for all colleagues. We respect an individual's right not to disclose this information. For this reason, a 'prefer not to say' option is included.

Date of Birth (dd/mm/yy)

St. David's believes that people should be judged, not by their age, but according to their skills and abilities at work. By monitoring our colleagues age we can ensure that opportunities for development and promotion are open to everyone.

National insurance number

Disability

Colleagues with a disability are entitled to reasonable adjustments under the law to enable them access to work.

Do you consider yourself to have a disability?

Yes

No

Ethnicity

By monitoring ethnicity, we can compare our recruitment pattern against the data collected in previous years’ National Census. This can show whether we attract people to work for us from all communities and whether as an employer, we reflect the communities we serve. We can also show whether all groups are treated fairly.

Religion or faith

Telling us about your religion or belief allows us to understand and plan to meet the particular needs of staff. It helps us to think about how we can accommodate requests to meet people's religious needs and faith. Knowing the religion of the staff helps us create an environment where all beliefs are respected.

Sexual orientation

Monitoring whether people are lesbian, gay, bisexual or heterosexual acknowledges that we value all staff and the contribution they bring to our business. An open and inclusive culture creates an environment where all colleagues can feel comfortable disclosing their sexuality. We know that people perform better when they can be themselves.