JOB APPLICATION FORM - Download Now DOC

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					Ashburton Surgery
JOB APPLICATION FORM
Please complete this accurately, giving as many details as possible of your skills and
experience.
Please send the completed application form to Ashburton Surgery at the address given on
the Practice Profile or email to: louise.killick@nhs.net
Position applied for:
 Job title:

APPLICANT’S DETAILS
 Title:              First name:                                                 Surname:



 Home address:




 POST CODE:

 Telephone numbers: please include full STD code
 Home:

 Work      :

 Can we contact you on this number during the working day? Yes/No

 Mobile (where possible):

 email address (where possible):


 Is there anything concerning your medical history or      Yes*/No
 state of health that is relevant to your application?     *If you answer Yes please refer to Part 2 of the Equality of Opportunity Questionnaire
                                                           enclosed

 Are there any restrictions regarding your employment?                                           Yes*/No
 e.g do you require a Work Permit?                                                               *If you answer Yes please supply details on a
                                                                                                 seperate sheet of paper

 Your National Insurance Number.

 Further information may be required under the Asylum & Immigration Act 1996 for shortlisted
 applicants only



 How many days have you had off work due to sickness during the last two years? Please note
 appointment may be subject to medical clearance




Ashburton Surgery
Application Form
 Have you ever been convited of a criminal office?                                                       Yes/No

 (declaration subject to the Rehabiliation of Offenders Act 1974 – clinical applications are exempt
 from this Act).

 Are you in possession of a recent Criminal Records Bureau check?
                                                                                                         Yes/No
 If yes state date completed




Additional Personal Information
 Do you have a valid driving licence for the UK?                                            Yes                No

 Do you have access to a vehicle which can be used for work purposes?                       Yes                No




Education & Professional Qualifications
 Include in this section all relevant qualifications. Please also indicate subjects currently being studied.

 Subject/Qualification                                Place of study                                     Grade/Result   Year




Ashburton Surgery
Application Form
Training Courses Attended
Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking.
Course Title                                         Training Provider                                Duration             Date Completed




Please record below the details of your previous employment beginning with the most recent first. Please explain any gaps in employment in the
"Supporting Information" section below. Please add additional employers/information on a separate sheet.




Ashburton Surgery
Application Form
Employment History
Please record below the details of your current or most recent employer.

 Employer Name


 Address




 Type of Business                                                  Telephone


 Job Title


 Start Date                                        End Date                           Start date of continuous
                                                                                      NHS service
 Grade                                                             Salary


 Reporting to
                                                                   Period of Notice
  (job title)
 Reason for leaving (if applicable)




 Description of your duties and responsibilities




Ashburton Surgery
Application Form
Previous Employer 1
Employer Name


Address



Job Title
                                                  Grade

From Date                                         To date


Reason for leaving




Description of your duties and responsibilities




Ashburton Surgery
Application Form
Previous Employer 2
Employer Name


Address



Job Title
                                                  Grade

From Date                                         To date


Reason for leaving




Description of your duties and responsibilities




Ashburton Surgery
Application Form
Supporting information
In this section please give your reasons for applying for a role at Ashburton Surgery. This can include relevant skills, knowledge, experience,
voluntary activities and training etc

 Supporting Information (Please continue on additional sheets if necessary)




Ashburton Surgery
Application Form
References

Please give the names of the people who have agreed to supply references. If you are, or have been, employed these should be your two most
recent employers. These may include your line manager or someone in a position of responsibility who can comment on your work experience,
competence, personal qualities and suitability for the post. All referees will be approached prior to interview unless you indicate otherwise.


Referee 1
Name


Job Title


Address




Postcode/Zip Code                                                                                                                            Country


Telephone                                                                                                                                    Fax


Email


Relationship                                                                                                                                   Can the referee be approached
                                                                                                                                                                                                              Yes                 No
                                                                                                                                               prior to interview?


Referee 2
Name


Job Title


Address




Postcode/Zip Code                                                                                                                            Country


Telephone                                                                                                                                    Fax


Email


Relationship                                                                                                                                 Can the referee be approached prior
                                                                                                                                                                                                              Yes                   No
                                                                                                                                                  to interview?
By signing and returning this application form you consent to Ashburton Surgery using and keeping information provided by you – or
third parties such as referees or educational institutions – relating to your application for future employment. This information will be
used solely in the recruitment process and will be retained for six months from the date on which you are informed whether you have
been invited to interview, or six months from the date of interview. Such information may include details relating to ethnic monitoring and
disability: these will be used solely for internal monitoring and will not be disclosed to any third party. You also understand that any
misrepresentation or material omission on this application or on any submitted CV will be sufficient cause for cancellation of this
application or immediate termination of employment if subsequently employed by Ashburton Surgery, whenever it may be disclosed.

 The information supplied in this application form is accurate to the best of my knowledge.



 .................................................................................................................................................................................   .........................................................................
 Signed                                                                                                                                                                                 Date

Thank you for completing the form.

Please print your completed form and return to Louise Killick, Office Manager at the address given
on the covering letter, or email to louise.killick@nhs.net
Ashburton Surgery
Application Form

				
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