PADDINGTON GREEN HEALTH CENTRE APPLICATION FORM - CONFIDENTIAL

Position applied for: . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personal Information Title (Mr, Mrs, Miss, Ms, etc.): Surname: Full Forenames: Previous names (if any): Current address:

Home telephone number: Mobile telephone number: Email address: National Insurance number:

Membership of Professional/Regulatory Bodies (as applicable) Organisation Registration Number

Renewal Date

Education and Qualifications From GCSE or equivalent to degree level in order of level of achievement eg degree to NVQ2 Establishment Qualifications Gained Grade / level if applicable

Professional Qualifications In chronological order Establishment Qualifications Gained Grade / level if applicable

Other Professional Courses Attended In chronological order Establishment Qualifications Gained Grade / level if applicable

Do you have any other training, qualifications or skills relevant to the post?

Employment History Please give details of your full employment history, beginning with your present or most recent. Name & Address Position Held Dates Responsibilities & Reason for Leaving

Please give details of any time not accounted for elsewhere on this application form.

Have you made a previous application to the Practice? If so, when and what was the outcome?

Please use this space to say why you are interested in the post for which you have applied and provide any other information that may assist your application. (continue on the Additional Notes page)

Have you been convicted of any criminal offences, which are not yet spent under the Rehabilitation of Offenders Act 1974? YES / NO Have you any prosecutions pending? YES / NO If yes, please give details:

If successful when can you start work? (please give earliest start date) Do you have any holidays booked? Please specify dates: YES / NO

Nurse and GPs only Have you any formal complaints outstanding outstanding? Yes/no The NHS Employment Check Standards require us to verify your identity and to seek proof of your right to work in the UK. If you are invited to interview you will be asked to bring with you original documentation to confirm your identity and to demonstrate your right to work in the UK. A list of acceptable documents can be found on: www.nhsemployers.org/RecruitmentAndRetention/Employment-checks If you require any special arrangements to be made so that you may attend interview, please detail this on the Additional Notes page. Dates you are not available for interview:

Declaration I declare that the information I have given on this form and within my Curriculum Vitae (as applicable) is, to the best of my knowledge, true and complete. I have omitted no facts that could affect my employment. I understand that if it is subsequently discovered that any statement is false or misleading, or that I have withheld relevant information, my application may be disqualified or, if I have already been appointed, I may be dismissed. I hereby give my consent to the Practice processing the data supplied on this application form for the purpose of recruitment and selection and may form the basis of any subsequent personnel file. Signed: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . . .
4

FOR OFFICE USE ONLY

SCREENED BY INVITE TO INTERVIEW REASON FOR DECISION YES / NO

ADDITIONAL NOTES
Name: . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Position applied for: . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .

EQUAL OPPORTUNITIES MONITORING FORM

Paddington Green Health Centre is committed to an Equal Opportunities policy in employment and will assess applicants for jobs without regard to disability, age, marital status, race, sex, or sexual orientation. To enable us to monitor our effectiveness with this policy, this form includes questions relating to those topics.
Please tick as appropriate: Age: 16-19 20-29 50-59 Gender: Male Marital Status: Single Partnership Ethnic Group: White-British Mixed-White & Black African Asian/Asian British Pakistani Black/Black British-African White Irish Mixed-White & Asian Asian/Asian British Bangladeshi Black/Black BritishOther White-other Mixed-White & Black Caribbean Asian/Asian BritishIndian Black/Black BritishCaribbean 60+

30-39

40-49

Female

Married

Divorced

Widowed

Mixed-Other Other Asian background Chinese

Other Please Specify Disability: If you are registered under the Disabled Persons (Employment) Act, please state: Nature of Disability: Registered Number: Certificate Expiry Date: Do you consider yourself to have a disability? If Yes please indicate Below Disability information: No Yes

Is there anyone who relies on you for day to day care and attention? YES NO If yes, are they: A) Children Aged 0-4 5-11 12-16 B) Other family member / partner Work Experience: None 5-10 years NAME: POSITION APPLIED FOR: DATE COMPLETED:

Less than 2 years More than 10 years

2-5 years

.. ..

For Equal Opportunities Monitoring Purposes Only