Application Form - St Lukes Hospice Cheshire

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Before completing this application form, we ask you to thoroughly read through the recruitment pack for the role. There is a detailed job description for the position, as well as a person specification at the back. This document will show you what experience is needed for the role and what evidence we need to see detailed on your application form. During shortlisting we will cross reference your application to the essential criteria requested for the role. Those who have evidenced all of this will be taken to the next stage of the process which is interview.

Vacancy applied for*

Name*

Email Address*

Address*

Home Phone Number

Mobile Phone Number*

National Insurance Number*

Not sure of your National Insurance Number? Click here.

NMC/GMC Pin No (for clinical staff only)

Do you have a full driving licence with access to a vehicle for business use?*

Do you have any UK employment restrictions?*

Please provide details:*

Where did you see this vacancy advertised?*

If you were informed of the vacancy by a St Luke's employee (as part of the Hospice's 'refer a friend' scheme) please state their name below.

Equality & Diversity Monitoring

St. Luke’s (Cheshire) Hospice recognises the benefits of having a diverse workforce and wants to meet the aims and commitments set out in its Equality and Diversity policy. This includes meeting the provisions of the Equality Act 2010 and building an accurate picture of the make-up of its workforce and to encourage and promote the principles of equality and diversity. The information you provide will stay confidential, and be stored securely and limited to the staff in the organisation’s Human Resources department for monitoring purposes.

Which of the following most accurately describe(s) your gender?*

Please specify*

Do you identify with the gender you were assigned at birth?*

If you would like to share your pronouns, please state these here:

Age*

Marital Status*

Religion or belief*

Please Specify*

Sexual Orientation*

Do you consider yourself to have a disability?*

Please describe the nature of your disability*

Please Specify*

Do you require any reasonable adjustments to enable you to fully participate in the selection process?*

What is your ethnic group?*

White or White British*

Please Specify*

Black or Black British*

Please Specify*

Asian or British Asian*

Please Specify*

Mixed*

Please Specify*

Other ethnic group*

Please Specify*

Requirements Under The Rehabilitation Of Offenders Act 1974

Because of the nature of the work for which you are applying this post may be exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975. Applicants therefore may not withhold information about convictions, cautions, reprimands or final warnings which would not be filtered in line with current guidance, and, in the event of employment, failure to disclose when asked any convictions, cautions, reprimands or final warnings that are not “protected” under the provisions of the Act (as amended in 2013) could result in disciplinary action or dismissal by the Hospice. Please note that convictions for minor traffic offences need not be declared.

If you are applying for a position to work in one of our Shops you do not need to answer this section.

Do you have any criminal convictions?*

Please disclose any convictions*

Qualifications

Please also indicate subjects currently being studied. Qualifications disclosed may be subject to a satisfactory check.

Qualifications*

Subject

Qualification

Place of Study

Grade

Year Obtained

Relevant Training Courses Attended

Course

Training Provider

Duration

Year Completed

Membership of Professional Bodies

Please indicate if you are a member of a professional body e.g. CIPD, GMC

Employment History - Present or Most Recent Employer

Job Title*

Employer*

Date of Commencement*

Leaving Date*

Time employed in role:*

Notice Period*

Salary*

Brief description of your duties and responsibilities*

Reason for leaving:*

Do you have other previous jobs?*

Previous Job

Job Title*

Employer*

Date of Commencement*

Leaving Date*

Notice Period*

Salary*

Brief description of your duties and responsibilities*

Reason for leaving:*

Do you have another previous job?*

Previous Job 2

Job Title

Employer

Date of Commencement

Leaving Date

Notice Period

Salary

Brief description of your duties and responsibilities

Reason for leaving*

If you wish to explain any gaps in your employment, please do so here:

Supporting Statement*

Please use this section to tell us why you feel you should be considered for this position including your reasons for applying for this role. If you are/or have been a volunteer at St Luke’s please outline your experience below. (Unlimited characters available)

References

Please provide the names and full contact details of the people who have agreed to supply references. References must as a minimum, cover the last three years employment and/or training history, where this is possible. Any offer of employment is subject to us receiving two satisfactory references. These references do need to come from your employer and not be a personal reference. References will not be approached until after a conditional offer has been made and accepted.

References will not be requested until an offer has been made.

Guidance: You must provide contact information for references covering your most recent employer, plus any other employers in the last 3 years. Please ensure these contact details are for the employer directly or the HR department.

Reference 1 Name*

Reference 1 Address

Reference 1 Email Address*

Reference 1 Contact Number*

Reference 1 Occupation*

Reference 2 Name*

Reference 2 Address

Reference 2 Email Address*

Reference 2 Contact Number*

Reference 2 Occupation*

Disclosure And Barring Service

St Luke’s Hospice uses the Disclosure & Barring Service (DBS) to help assess the suitability of applicants for relevant roles. The appointment to this Hospice post may be made subject to a disclosure check, and barred lists checks where applicable. Disclosure will not necessarily bar you from employment by St Luke’s Hospice. This will depend on the circumstances and background of your offences, and also relevance to the post. If you are offered a position with the Hospice, you will be required to provide original documentary evidence for proof of identity purposes.

If you are applying for a position to work in one of our Shops you will not be required to have a DBS Check..

Declaration

The information you provide on this form will be used to progress your application for employment and, if your application is successful, to administer your personnel record. Before starting your application and inputting your personal details. By choosing to sign the box below, you consent to the terms of the Privacy Notice and are agreeing to your information being held and used as described above.

Consent*

I consent to my submitted data being collected and stored | Privacy Policy

Job Application Form

Equality & Diversity Monitoring

Requirements Under The Rehabilitation Of Offenders Act 1974

Qualifications

Employment History - Present or Most Recent Employer

Previous Job

Previous Job 2

References

Disclosure And Barring Service

Declaration

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