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									Application for employment (in confidence) Trust Staff Bank New City Court Guy’s Hospital Great Maze Pond London SE1 9RT
PLEASE COMPLETE THIS APPLICATION FORM IN TYPE OR BLACK INK. If you have any difficulty completing this form please ask someone to help you. We would like to take this opportunity to thank you for applying. Post applied for _______________________________Reference No_________________ Source of Application __________________________ Closing Date__________________
(please specify)

Personal details Second_____________________________ Title (Mr Ms Miss Dr)_____________ First Name(s)_______________________ Tel. (Work) ________________________

Address _____________________________ Tel. (Home) _______________________

____________________________________ Mobile ___________________________ _________________Post Code___________ Email__________________________
First Available Date for Employment__________ Work Permit Number_____________
(if appropriate)

Do you need a work permit for employment in this country? Yes/No

References Please give the names and addresses of two referees in the space below. If you are currently working, one reference must be your current employer. For all applications, the other referee should be a previous employer, school or college. Friends and relatives must not be used as referees. Please also state the capacity the referee knows you in, for example manager, head teacher or lecturer. Name: __________________________ Name: _____________________________ Address: __________________________ Address: _____________________________

_________________________________ _________________________________ ___________Post Code _____________ Capacity _________________________ Tel No _________________________ Fax No _________________________ Mobile _________________________ Email _________________________

____________________________________ ____________________________________ _______________Post Code ____________ Capacity ____________________________ Tel No ____________________________ Fax No ____________________________ Mobile ____________________________ Email ____________________________

Education and Training Schools (since age 11) From


Exams Taken



University/College/ Nursing School






If you are state registered please complete the following section: Registration No. Date of Registration Expiry/Renewal Date

If you have other professional qualification(s) please complete the following section: Qualification Registration No Date Obtained

Please give details of other formal training courses attended and dates (e.g. Management, post registration/Enrolment)

Proposed Further Qualifications:

Present or most Recent Employment (including Nurse Training) From: __________ To: _______________ Employer’s Name and Address: Post Held and main duties

__________________________________ __________________________________ __________________________________
Grade: ____________________________ Salary: ____________________________

___________________________________ ___________________________________
Telephone No: ______________________ Reason for Leaving: __________________

Employment prior to above starting with most recent: Employers Name From To Post held, grade and Address (if applicable and main duties

Reason for Leaving

Please read the job description and person specification carefully and make full use of this section, attaching additional sheets if necessary, to provide further information in support of your application. Please be sure to include: i) The reasons why you are applying for the post. ii) Details of any relevant experience gained either in a paid or voluntary capacity. iii) Details of any training, education or other interests relevant to the post.

Disclosure of Information a) Are you related to an employee of this Trust or a member of the Trust’s Members’ Council? Yes No Name_________________________Post_______________Relationship__________________ b) Have you ever been dismissed from previous employment? Yes/No

Post__________________________Date_________Reason____________________________ c) Because of the nature of the work concerned this post is exempt from the provisions of Section 4 (2) of the Rehabilitation of Offenders act 1974. You are not entitled to withhold information about convictions which for other purposes are ‘spent’ under the Provisions of the Act. Any such information given will be completely confidential and will be considered only in relation to your application for the post. Any convictions should be listed on a separate sheet of paper, and placed in a sealed envelope, addressed to the Staff Bank Manager. IMPORTANT NOTE The following will result in disqualification or dismissal: i) Canvassing a member of the Trust’s Council or a senior member of Trust Staff. ii) Failure to disclose a relationship with a member of the Trust’s Members’ Council or an employee of the Trust. iii) Failure to disclose convictions, including ‘spent’ ones if applicable (see above). iv) The provision of false information either expressly or implicitly. I certify that the above information is correct. Signature ____________________________________ Date __________________________

The Trust is committed to providing equal opportunities for all job applications, employees and users of its service, and is opposed to all forms of unlawful and unfair discrimination. The Trust has a comprehensive equality and diversity programme and works hard to reflect the cultural and ethnic diversity of the communities it serves All job applications are considered equally, regardless of the applicant’s gender, sexual orientation, marital status, responsibility for dependents, disability, race, national origin, age, religion, political or trade union affiliations, HIV status or socio-economic background. We collect information on ethnic origin, gender and disabilities from all applicants. This helps us to make sure that our employment policies are working effectively. The information you provide below is for monitoring purposes only, and will be treated in the strictest confidence. The questionnaire will be separated from the rest of your application form before selection for interview. Post applied for _____________________________________________________________________ Reference number ___________________ Department ____________________________________ Second name ____________________________ Previous second name _____________________
(if applicable)

First name(s) ____________________________Date of Birth _______________________________



Ethnic Origin What is your ethnic group? Choose ONE section from A to E, and then tick the appropriate box to indicate your ethnic group.
(a) White British  Irish  Any other  Background Please write in Below) (b) Mixed (c) Asian or Asian British (d) Black or Black British (e) Chinese or other ethinic group Chinese 

White and Black Caribbean White and Black African White and Asian Any other mixed background (please write in below)

Indian Pakistani 

 

Caribbean African

Any other not 

Bangladeshi  Any other (please   Any other Asian   (please write in write in below)
background (please write in below) below)

Disability Do you consider yourself to have a medical condition or disability? Do you consider yourself to have a medical condition or disability Which requires support in the workplace? Yes No Yes No

If you are selected for interview, you will have the chance to let the Bank Office know about any particular needs you may have. This will enable us to offer you a fair interview if for example, you have a speech difficulty or need a wheelchair accessible room.

Signature: ________________________________ Date: ___________________________

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