HIRST MEDICAL GROUP

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					                          Appointment Application Form

Job Title: Medical Receptionist                              Form Ref No: 1:11/13
                                                             (Practice Use only)


Notes:
   Please read all of these notes before completing this application.
   As this application will be photocopied, please complete the form in black ink or
    typescript.
   PERSONAL DETAILS ARE REMOVED BEFORE SHORTLISTING.
   C.V.s will NOT be accepted.
   IF YOU WOULD LIKE THIS FORM IN WORD FORMAT PLEASE EMAIL
    gillian.rigg@gp-a84028.nhs.uk


Patient Registration
Successful applicants will be required to register with an alternative GP Practice if currently
registered with one of the predecessor practices as a patient.
Families of employees may remain on the list.
Criminal Records Bureau Clearance
Successful applicants may be required to complete a CRB Disclosure Application Form.


Personal Details
Surname:                         Forename(s):                                Title:


Postal Address:



                                                 Postcode:

Home Tel no:                                     Work Tel no:

Mobile Tel no:                                   E Mail:


May we call you at work                       YES / NO

Date of Birth:                                   National Insurance Number:


Full Driving Licence: YES / NO                   Use of own car: YES / NO




Seaton Park Medical Group. Employment Application Form. Last updated 03/10/12         Page 1 of 7
                                 Monitoring Information

THE FOLLOWING INFORMATION IS USED FOR MONITORING PURPOSES ONLY.

Employment Equality Regulations 2003
In order to ensure compliance with these regulations we are monitoring sexual
orientation and religion/belief in applications. Please answer the following questions:

Gender:             Male           Female

Marital Status:     Married        Single         Separated        Divorced           Other

*Please indicate your religious belief

*Please describe your sexuality


Race Relations (Amendment) Act 2000
Please note that ethnic origin questions are not about nationality, place of birth or
citizenship. U.K citizens can belong to any of the ethnic groups indicated below:

 *I would describe my ethnic origin as (indicate one only):
1   Asian or             5 Black British/           9   Mixed White &           13   White British
    Indian                  Black African               Asian
2 Asian British/         6 Black or                 10  Mixed White &           14   White Irish
    Bangladeshi             Black Caribbean             Black African
3 Asian British/         7 Black Other              11  Mixed White &           15   Other White
    Pakistani                                           Black Caribbean
4 Asian Other            8 Chinese                  12  Other Mixed             16   Other Ethnic
                                                                                     (please specify)


Disability Discrimination Act 1995
Under the terms of the act a disability is defined as a ‘physical or mental impairment
substantial and long term effect on a person’s ability to carry out normal day to day
functions’. We welcome applications from disabled people.

*Do you consider yourself to be disabled?                                                Yes/No

Are you Registered Disabled?                                                             Yes/No

If you have a disability, do you need any special arrangements to enable you to attend for
interview? If so, please give details.




Work Permit
A work Permit will be required for applicants from outside the EEA. An employer will not be
able to get a work permit for an applicant if the post can be filled by a UK or EEA resident.

*Do you require a UK Work permit under the terms of the Immigration and Asylum Act
1996?
                                                                            Yes/No
If you have a permit Details of the Permit currently held



Seaton Park Medical Group. Employment Application Form. Last updated 03/10/12        Page 2 of 7
CRB Clearance
Please advise any details which will be disclosed on CRB check

*Have you at any time received, or pending a court conviction?                           Yes/No
If so, please give details.




*Have you at any time received a caution?                                                  Yes/No
If so please give details




DECLARATION
Please complete all parts of this application form, before signing this declaration.

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE ALL THE INFORMATION I HAVE
GIVEN IS CORRECT. I UNDERSTAND THAT DELIBERATELY GIVING FALSE OR
INCOMPLETE ANSWERS WOULD DISQUALIFY ME FROM CONSIDERATON, OR IN
THE EVENT OF MY APPOINTMENT, MAKE ME LIABLE TO DISMISSAL WITHOUT
NOTICE.

Signed:                                                              Date:




Please return to:             Mrs Gillian Rigg
                              Management Support Assistant
                              Seaton Park Medical Group
                              Seaton Hirst Primary Care Centre
                              Norham Road
                              Ashington
                              NE63 0NG

Data Protection Statement

The information that you provide on this form and that obtained from other relevant sources
will be used to process your application for employment. The personal information that you
give us will also be used in a confidential manner to help us monitor our recruitment process.

If you succeed with your application and take up employment with us, the information will be
used in the administration of your employment with us and to provide you with information
about us or a third party. We may also use this information if there is a complaint or a legal
challenge relevant to this recruitment process. We may check information collected, with
third parties or with other information held by us. We may also use or pass to certain third
parties information to prevent or detect crime, to protect public funds, or in other ways as
permitted by law.

By signing the form we will be assuming that you agree to the processing of personal data, in
accordance with our register with the data Protection Commissioner.




Seaton Park Medical Group. Employment Application Form. Last updated 03/10/12          Page 3 of 7
EMPLOYMENT HISTORY
(Continue on separate sheet if necessary)

Most recent employer’s name and address:            Job Title:


                                                    Grade and salary:


                                                    Date commenced:


                                                    Reasons for leaving (or considering
                                                    doing so) –
                                                    THIS MUST BE COMPLETED


Brief description of duties and responsibilities:




Previous Employment (last 10 years only)
(Please explain any gaps)

Employer’s name and address:              Dates            Job Title            Reason for
                                                                                 leaving




Seaton Park Medical Group. Employment Application Form. Last updated 03/10/12      Page 4 of 7
EDUCATION TRAINING AND QUALIFICATIONS
Please give details of educational qualifications you have obtained from school, college,
university, etc.




WORK RELATED TRAINING
Please give details of any training you have undertaken.




MEMBERSHIP OF PROFESSIONAL BODIES/PROFESSIONAL
QUALIFICATIONS
        Name of body/qualification                      Class/grade of membership




Seaton Park Medical Group. Employment Application Form. Last updated 03/10/12     Page 5 of 7
REASON FOR APPLYING
Please tell us WHY you are applying for this post – if you are in current employment
this must include your reasons for considering leaving your current job.

Please note: This section MUST be completed by ALL applicants (a clearly identified
separate sheet may also be used)




SKILLS, KNOWLEDGE AND EXPERIENCE
Please give details of skills, knowledge and experience relevant to the job (see Person
Specification), gained either in previous jobs, or from activities outside employment.
Please describe how you feel your skills and personal attributes fit with the
requirements of the job.

Please note: This section MUST be completed by ALL applicants, CVs are NOT
accepted. (a clearly identified separate sheet may also be used)




Seaton Park Medical Group. Employment Application Form. Last updated 03/10/12   Page 6 of 7
HEALTH
All candidates must be medically fit to carry out the duties of the job for which they are
applying. A successfully candidate will be asked to complete an Occupational Health
Questionnaire and may be called to undergo a medical examination. Please note that all
offers of employment are subject to satisfactory health clearance and this clearance must be
received before the successful applicant may start work.


GENERAL INFORMATION

Do you hold a current driving licence?                                             YES / NO

If yes:        State type

               Does it carry any endorsements?                                     YES / NO

               If yes please state nature:


Do you have a car which would be available for use at work (if required)?          YES / NO



REFEREES
Please give the names and addresses of two referees. If you are, or have recently been,
employed either on a paid or voluntary basis, please give your current or most recent
employer as a referee.

If you are in, or have just completed full-time education, one referee should be from your
school/college.

Do not use a relative.

Name:                                           Name:



Address:                                        Address:




Telephone Number:                               Telephone Number:

Position Held:                                  Position Held:




Seaton Park Medical Group. Employment Application Form. Last updated 03/10/12     Page 7 of 7

				
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