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					Application form August 2009
TITLE (Mr/Ms/Dr etc.)

SURNAME

FIRST NAME

JOB TITLE

WORK ADDRESS




POSTCODE

WORK TEL :

HOME TEL:

MOBILE TEL :

EMAIL

CORRESPONDENCE ADDRESS (IF DIFFERENT FROM ABOVE)




SELECT DATES YOU ARE AVAILABLE FOR INTERVIEW


SEPTEMBER 1st Yes/No (delete as appropriate)
SEPTEMBER 2nd Yes/No (delete as appropriate)
SEPTEMBER 4th Yes/No (delete as appropriate)



THIS APPLICATION IS CONFIDENTIAL TO NHS LONDON. PLEASE USE THIS APPLICATION ONLY. CLOSING
DATE TO RECEIVE COMPLETED APPLICATION IS 5PM on AUGUST 12 2009.


EMAIL THIS MS WORD FORM BY AUGUST 12 TO: Leadingforhealth@london.nhs.uk

NOTE: PLEASE PRINT PAGE 8 (SIGNATURE/ENDORSEMENT) AND SEND, BY AUGUST 12 TO :

Hannah Reed
NHS London,
Southside,
105 Victoria Street,
London SW1E 6QT
Please describe your current roles and responsibilities including your leadership competencies,
examples of how you have applied them and the outcomes achieved as a result of this.
Please describe your career to date and the career and educational decisions you have made.
How do you see your career developing in the future?
What draws you to participate in the Aspiring Nurse Directors Leadership Programme?
What excites you about participating in this programme at this point in your career?
What do you think you need to personally learn to become an effective leader?
Applicant:

I understand that once my application is accepted, I am committed to complete the Aspiring
Nurse Directors Leadership Programme in full.

Should I prove to be unsuccessful in my application, I commit to undertake further mentoring.

All details and statements provided are true and correct.



NAME: _______________________________________ JOB TITLE: _____________________________

SIGNATURE: __________________________________                 DATE: ________________________________




Nursing Director’s Endorsement:
I understand my commitment to support this applicant as detailed and I undertake to release him/her
for the complete duration of the programme modules as required.

Should the applicant prove to be unsuccessful in their application, I undertake responsibility to further
develop the applicant by personally committing to the mentoring and development of the applicant.



NAME:________________________________________                 JOB TITLE: Director of Nursing_____________

SIGNATURE: __________________________________                 DATE: ________________________________
Equal Opportunities Monitoring Form for Delegates/Programme Participants

Thank you for completing this form. Both The King’s Fund and NHS London are committed to
equal opportunities and the information collected on it will be used only for the return of
anonymised information to inform ethnic monitoring, equal opportunities and diversity
policy standards.
Instructions: Please write ‘X’ beside your selection below.

 1. Programme: Aspiring Nurse Director Leadership Programme


 2. Gender:  Male      Female                      ASIAN
                                                      Asian British
 3. I would describe my                               Indian
    ethnic origin as:                                 Pakistani
    (please tick appropriate box)                     Bangladeshi
                                                      Other Asian (please specify)
   WHITE
  English                                         ________________________________
    Irish
    Scottish                                        BLACK
    Welsh                                            Black British
    Other white (please specify)                     Caribbean
                                                      African
    ________________________________                  Other Black (please specify)

    MIXED                                            ________________________________
     White & Black Caribbean
     White & Black African                           CHINESE
     White & Asian                                  OTHER ETHNIC GROUP
     Other Mixed (please specify)                   (please specify)

    ________________________________                 ________________________________


 4. Do you consider that you have a disability? Yes          No

 5. Do you have a disability as defined by the Disability Discrimination Act 1995?
     (This means a physical of mental impairment which has a substantial and long term adverse
    impact on your ability to carry out your normal day to day activities)

    Yes         No          Don’t Know

				
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Description: AND Application form