Clinical Commissioning Groups – Application Form
Lay Member - Governance
Thank you for your interest. This application form can be completed on your own PC, and
returned by email to firstname.lastname@example.org If you are completing the application form by
hand please use black ink to assist with photocopying. The form must be returned to the
Staffordshire Cluster of Primary Care Trusts with your CV and any continuation sheets. (FAO:
Sally Young, Staffordshire Cluster, Headquarters, Blackheath Lane, Stafford ST180YG )
The Staffordshire Cluster of Primary Care Trusts is committed to ensuring that all appointments
are made in a way that is open, transparent and fair to all applicants. All appointments are made
Your personal details
Home contacts Home Phone Mobile
Fax No Email
Preferred e-mail address
Please indicate your
profession or background
Position being applied for
Please indicate which CCG you are applying to, and describe your interest and engagement with
the locality selected (e.g. residence, work etc…)
Delete as appropriate:
East Staffordshire / Cannock Chase / Stafford and Surrounds / South East
Staffordshire & Seisdon Peninsular / North Staffordshire /Stoke
NHS or other Dept. of Health posts held
Have you held any positions within the NHS or Department of Health, either employment or
consultancy in the past 12 months?
If yes, please give details
Organisation Post Dates
Have you held any other chair or non-executive positions in the health and social care sectors
in the past 3 years?
If yes, please give details
Organisation Post Dates
Ministerial appointments currently held
Candidates for appointment are required to give full information about any ministerial
appointments they hold. You should also include details of any current NHS board appointments
you hold. Please ensure that you include full details of the body to which you have already been
appointed, the period of appointment and annual remuneration or daily fees paid.
Do you currently hold any ministerial appointments made by or on behalf of Ministers?
If "yes" please give the following additional information
Body Period of appointment Payments Government
From To received Department
Declaration of interests
Do you have any business or personal interests that might be relevant to the work of the body
for which you have applied and which could lead to a real or perceived conflict of interests were
you to be appointed? (Failure to disclose such information could result in an appointment being
If yes, please give details below:
Ensuring public confidence
Should you be successful in your application, is there anything about your professional or
personal history which, if brought into the public domain, may cause embarrassment or
disrepute to the organisation. Failure to disclose such information could result in an
appointment being terminated.
If yes, please give details below including dates:
Have you received a prison sentence or suspended sentence of 3 months or more in the last 5
years? Failure to disclose such information could result in an appointment being terminated.
If yes, please give details below including dates:
Please give details of two referees who will support your application, at least one of whom must
be from a “line management capacity” related to your most recent professional and / or
voluntary activity. If you are invited to interview we may contact them at this stage. An
appointment will not be offered until we have received satisfactory references.
Home Phone Home Phone
How do you know How do you know
him / her? him / her?
The role description gives details of the particular skills and experience sought. Please read this
information carefully before completing this section of your application. This is important, as the
initial selection will be based on the extent to which you have demonstrated the expertise
required. If you do not have any essential experience at the level required your application will
not be considered further. The people who best demonstrate the essential experience required
for the post will then be assessed against the desirable expertise and this will be used to
differentiate between applicants otherwise of equal merit.
Essential: Please provide details about recent and relevant financial and audit experience,
sufficient to enable competent engagement with financial management and reporting in the
organisation and associated assurances. Please highlight relevant skills and experience
and any relevant education or training and refer examples back to the role description
Essential: Please provide evidence of your senior level governance experience,
demonstrating strategic planning, financial, risk and performance management. You will
need to demonstrate you have the skills, knowledge and experience to assess and confirm
that appropriate systems of internal control are in place for all aspects of governance
including financial and risk management. You will need to demonstrate an understanding of
the resource allocations devolved to NHS bodies, and a general knowledge of the
accounting regime within which a CCG will operate. Your response should highlight key
areas and personal achievements in your career history, details of your level of
responsibility and decision making.
Essential: Please provide evidence of a time when you have worked as part of a team and
collaboratively with other stakeholders, particularly commenting on your relationship
development and leadership skills. You will need to demonstrate exceptional leadership
qualities with the ability to chair committees effectively, be able to demonstrate recognition
and respect by peers and be able to establish credibility with all stakeholders and partners,
especially patients, healthcare professionals and service providers.
Essential: Please explain your understanding and commitment to the public service values
of accountability, probity, openness and equality of opportunity. For example, you could give
examples of instances when you have applied these – at work, in voluntary work or in
Please enclose a brief, up to date CV (no more than 2 sides of A4) outlining your employment
history, any relevant voluntary work, public service or other experience, together with any
relevant professional, academic or vocational qualification. Your CV will be used to assist the
assessment of your expertise.
Monitoring information is not used in the selection process and will not be seen by the panel
assessing your application. However, as these are public appointments, basic information
about those appointed may be made public in a variety of official publications.
Date of birth
White Black Asian/Asian Chinese Mixed
British African Bangladeshi Chinese Asian & white
Irish Caribbean Indian Any other Black African &
Any other white Any other black Pakistani background
background background Black
Any other Caribbean &
Many people do not consider themselves to be disabled, but under the Disability Discrimination
Act you can consider yourself disabled if you have a physical or mental impairment or long term
health condition, and the effects are expected to last, or have lasted for a year or longer, and
have a substantial effect on your ability to carry out day to day activities; or your day to day
activities would be limited without medication, treatment or adjustments (for example the use of
inhalers, physiotherapy, a hearing or visual aid or insulin).
Taking this into account, do you consider yourself to be a disabled person?
If you are disabled and in receipt of benefits you need to be aware that under current
regulations a paid public appointment may affect your entitlement.
We are particularly keen to recruit disabled people who have the necessary skills. To
encourage those applicants we operate a scheme under which disabled candidates, who have
demonstrated the level of experience/expertise required for the post, will be assured of an offer
of an interview.
Would you like your application to be considered under the Interview Access Scheme?
All applicants for a public appointment should complete the question below. This question is
asked as it enables the monitoring of political activity of candidates for a public appointment in
so far as it is already in the public domain. Neither activity nor affiliation is a criterion for
appointment (except where statute dictates specific representation). If you are successful, the
information will be published in the announcement of your appointment.
Please indicate which of the following activities you have undertaken during the past five years
by ticking the appropriate box and by providing details of your involvement. Name the political
party or body for which you have been active. If you have been or are an Independent or have
sought or obtained office as a representative of a particular interest group, you should state this.
You should tick all relevant categories.
Obtained office as a Local Councillor, District Councillor MP, MEP, MLA etc.
Stood as a candidate for one of the above offices
Spoken on behalf of a party or candidate
Acted as a political agent
Held office such as Chair, Treasurer, or Secretary of a local branch of a party
Canvassed on behalf of a party or helped at elections
Undertaken any other political activity which you consider relevant
Made a recordable donation to a political party*
None of the activities above apply
Name of Party for which activity undertaken
Conservative Liberal Democrats
Other Please specify
Details of involvement:
* The Political parties, Elections and Referendums Act 2000 requires the Electoral Commission to publish a
register of recordable donations (donations from any individual totalling £5000 in any calendar year, or more
than £1000 if made to a subsidiary accounting unit such as a constituency association, local branch,
women’s or youth organisation). These provisions became effective from 16 February 2001.
Note: This information is for monitoring purposes only and therefore will be detached from your
application and will not be seen by the selection panel. However, it is appreciated that such
activities may have given you relevant skills, including experience gained from committee work,
collective decision making, resolving conflict and public speaking. If, therefore, you have had
such experience and you consider it relevant to your application for this post, you should include
it separately in the main body of your application form. You should not, however, identify the
relevant political party in the application form.
Publication of monitoring information
Information on the composition of some public bodies by gender is published in the Cabinet Office's
publication "Public Bodies". Information about the ethnic origin and disability of public appointees is
occasionally published, in response to Parliamentary Questions and other public enquiries, but never in a
way that would enable individuals to be identified. The Data Protection Act requires that those providing
this information must be informed and their consent given, even though individuals are not identified.
Please tick the relevant box to show whether you are content or not content for your monitoring
information to be used in this way.
Do you consent, therefore, to this information being made publicly available?
How you found out about this post
To help us to target our recruitment activity more effectively and publicise posts in the future, it
would be helpful if you could let us know how you found out about the vacancy.
How did you find out about this post?
To the best of my knowledge and belief, the information given in this form is complete and correct. I have
considered and understood any criteria for disqualification from appointment and I am not disqualified. I
understand that if I am appointed and any of the information I have provided is subsequently found to be
untrue then my appointment may be terminated. I confirm and accept these conditions.