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					                                Confidential Application Form
Please complete and return to:
Human Resources Department, Park House, 184 Kennington Park Road, London SE11 4BU

Position applied for:

Your Personal Details
Mr/Mrs/Ms/Miss/Dr please circle

Surname                                       Forenames


Telephone no. (home)                          Telephone no (work)
Mobile phone no.                              May we ring you at work?

Email                                         If appointed, how soon could you start work?

National Insurance Number                     Do you need a work permit for the UK?

How did you hear about this position?

Do you have a health problem or disability that you consider to be relevant to your

If yes, please specify

Disabled people who meet the criteria in the person specification will be shortlisted for
interview. Please contact Sam Ha [on 020 7840 9778 or at the above address] separately if
you need us to make particular arrangements for completing the application form, attending
an interview, or any reasonable adjustments that would need to be made to the job or
working environment if your application is successful.

The Health Professions Council is working towards equality of opportunity in
employment and to this end, the front sheet of your application form and the Equal
Opportunity & Diversity Monitoring Form, will be detached prior to submitting
application forms for shortlisting.
Present (or previous) Employment

Name and address of employer

Position held                                      From:                  To:

Reason for leaving                                 Salary

Brief description of duties and responsibilities

Employment History (Most recent first)

Dates           Employer and Position                 Duties and reason for leaving
Please give details of your secondary and higher education (or equivalent), starting with the
most recent.

School/College/University         Dates                 Subjects/Qualifications/Grades

Other Qualifications/ Training
Please list any other training, short courses or professional qualifications you have

Supporting Statement

Please use this space, and a continuation sheet if necessary, to:
    Explain why you are applying for the job
    Describe how your experience, skills, knowledge and education and training meet the
      person specification and are relevant to the job description. Include experiences of
      outside work
    Provide any other information that is relevant to your application.
Additional Information
Please give any additional information that may be relevant for this application, such as the
dates of forthcoming holidays when you cannot be contacted.

Please give the names and addresses of 2 professional referees (from a Line Manager or
someone in a position of responsibility who can comment on your work experience).
References should be from your 2 most recent employers and should cover your last 3 years
of employment. If you are a student please provide contact details of a teacher at your school,
college, or university. Referees will not usually be contacted until a preliminary job offer has
been made, and will not be contacted without your consent.


Name and address of organisation

Telephone no                      How do you know this referee?


Name and address of organisation

Telephone no                      How do you know this referee?

Data Protection

The information on this application form will be held securely, both manually and on HPC’s
personnel computer database, and will not be divulged to anyone outside the organisation.
Information on the successful candidate may be held indefinitely. Information on unsuccessful
candidates will be held for up to two years.

We reserve the right to verify the information you have provided and seek information from
other sources.

The information on the equal opportunities monitoring form will only be used for
monitoring our equal opportunities policy. Any information required for statistical
analysis will be used anonymously.
I declare that all the information given on this form is, to the best of my knowledge, complete
and correct. I understand that if I am employed and any of the information I have provided is
false, my contract may be terminated.

If you wish to receive an acknowledgement receipt of your application, please fill out the below:

Position: _________________________________

                 Private and Confidential

Name:     __________________________________

Address: __________________________________

Equal Opportunities and Diversity Monitoring Form (Employees and
Thank you for applying to a vacancy at the HPC. This monitoring form which we ask
you to fill in and submit with the rest of your application is to help us monitor and
improve our standards of recruitment and employment practice.

The HPC is committed to equal opportunities, and reflecting the diversity of the public.
To monitor our recruitment process we collect diversity data on all applications, which
is stored separately from the rest of your application and is not seen by any shortlisting
or interview panels. It is used to produce statistics so that we can analyse the diversity
profile of those applying to the HPC and meet the obligations of our Equality and
Diversity Scheme.

Gender               Male        Female             Prefer not to say

Transgender          Male                        Female                      Prefer not to

Age                  Up to 18 years                  46-55 years

                     19-25 years                     56-60 years

                     26-35 years                     over 60

                     36-45 years                     Prefer not to say

Date of Birth        ___________________

Marital Status       Single                          Widowed

                     Married                           Partner

                     Divorced                  Prefer not to say

                     Civil Partnership

Do you have          No             Yes          If yes, please indicate number:________
                           Prefer not to say

    Do you consider        No                    Yes              Prefer not to say
    yourself to have a
    disability?            If yes, please indicate the type(s) of impairment that apply to you:

                           Physical impairment                     Sensory impairment

                           Mental health condition             Learning disability

                           Long standing illness
                           or health condition


                           Please specify if you wish: _______________________

Ethnic Group

What race or ethnicity do you consider yourself?
Choose ONE section from A to F, and then tick the appropriate box to indicate your cultural
A       White

                         English                       Scottish

                         Welsh                          Northern Irish

                 Irish                                 Any other White background: ____________

B       Mixed
                 White and Black Caribbean             White and Chinese
                 White and Black African               Any other Mixed background: ____________

C       Asian, Asian British, Asian English, Asian Scottish, or Asian Welsh
                 Indian                          Bangladeshi
                 Pakistani                       Any other Asian background: ____________

D       Black, Black British, Black English, Black Scottish, or Black Welsh
                 Any other Black background: ____________________

E       Chinese, Chinese British, Chinese English, Chinese Scottish, or Chinese Welsh, or
        other ethnic group
                 Any other ethnic background: __________________

F       Prefer not to say


Religion or Belief

    Which group do
                             No religion                   Hindu
    you most identify
                             Baha’i                        Jain

                             Buddhist                      Jewish

                                Muslim                         Sikh

                             Christian                     Any other religion or belief
                             Prefer not to say         (specify if you wish) __________


Your Sexual Orientation
Bisexual                   Gay Woman/Lesbian           Prefer not to say

Gay Man                    Heterosexual/Straight

Other                      Specify if you wish: ____________________

Applicant Name: ____________________ Date Completed: _________________

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