Ward Clerk

Title

Forename

Surname

Former Surname(s)

Telephone (home)

Telephone (mobile)

May we contact you at work?*
Yes    No

E-mail address

Address

Postcode

NI Number

Are you free to remain and take up employment within the UK with no current immigration restrictions?* Yes    No

Please indicate how you learnt of this vacancy
Please select St David’s Website Job Site Shop Window Social Media Other…

Name of professional body

Membership Status

Registration Number (PIN for Qualified Nurses)

Year of Registration

Employer’s Name

Employer’s Address

Type of Business

Date Started

Date Left (if applicable)

Salary

Notice Period (if applicable)

Reason for leaving

Position Held

Hours*
Full Time     Part Time

Brief description of duties

Please include a full employment history since leaving full time education accounting for any gaps, most recent first.

Please note any other employment, paid or unpaid, you would continue with if you were successful in obtaining this position.

Please note here your leisure interests, sports and hobbies, other pastimes, etc.

Please describe how you meet the criteria set out in the Job Description and Person Specification, giving details on your specific reasons for this application, your main achievements to date and the strengths you would bring to this post.

Please give details of any criminal convictions. If none, please state.

If, due to the nature of the work for which you are applying (please refer to Job Description / Person Specification) your application is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974, (Exemptions) Order 1975, you will not be entitled to withhold information about convictions which are for other purposes 'spent' under the provisions of the Act. In the event of employment, any failure to disclose such convictions could result in dismissal. Successful candidates will be required to complete a Disclosure Application at Standard or Enhanced level, depending on the nature of the post, for submission to the Disclosure Barring Service. St. David's Hospice Care complies fully with the DBS Code of Practice and the Data Protection Act 1998 regarding disclosure information. Any information given will be treated as completely confidential and will only be considered in terms of its relevance to an application for positions to which the order applies. A criminal record will not necessarily be a bar to obtaining a position. If you have any concerns or queries on this matter, please seek advice from the HR Manager.

Do you hold a current UK driving licence?*
Yes     No

Are there any restrictions on you taking up work in the UK?*
Yes     No

Please give below the names of two referees who have agreed to give a reference on your behalf and who are not related to you. One of them should be your existing or most recent employer.

Referee 1

Name

Your relationship to referee

Dates known

Organisation

Address

Contact Number

E-mail address

May we contact this referee prior to interview?*
Yes     No

Referee 2

Name

Your relationship to referee

Dates known

Organisation

Address

Contact Number

E-mail address

May we contact this referee prior to interview?*
Yes     No

Have you had a recent bereavement of a close family member or friend?*
Yes     No

We advise a person who has had such a bereavement not to begin employment at St David’s Hospice Care until at least one year has elapsed. If, however, you feel able to begin employment and would like to discuss the possibility of doing so, please contact the Personnel Manager, who will be happy to discuss this with you.

I confirm that the information given on this application form and any attachments is to the best of my knowledge and belief true and correct. I declare that I have not knowingly provided false information in support of my application. I fully understand, however, that if any details should prove to be false then this will automatically disqualify my application and give my employer the right to terminate any employment contract offered.

I agree that the organisation reserves the right to require me to undergo a medical examination.

I hereby give my consent to St David’s Hospice Care processing the data supplied in this form for the purpose of recruitment and selection. Please refer to our Privacy Policy for full details of how we process your information.

Data protection: Information from this application may be processed for purposes registered by the Employer under the Data Protection Act 1998. Individuals have, on written request the right of access to personal data held about them.