APPLICATION FOR EMPLOYMENT

PERSONAL DETAILS

EDUCATION DETAILS

Title:

Please tell us about your education and any qualifications which you feel are relevant to the post. Type of Institution

Are you a member of any Professional Body?: Yes

Yes

No No

Qualification Level

Subject studied Date obtained

Surname: First Name: Home Address: Post Code: Email Address: Contact Number:

Do you hold a current clean driving licence?: Reference Number:

PLEASE COMPLETE IN BLACK INK

INCORPORATING

EMPLOYMENT DETAILS

Please tell us about previous employment starting with the most recent (please include both paid and voluntary experience)

Name of Employer:

Name of Employer: Reason for Leaving:

Reason for Leaving: Job Duties: Job Duties: Position Held: Position Held: Dates from: Dates from: To: To:

EMPLOYMENT DETAILS

Please tell us about previous employment starting with the most recent (please include both paid and voluntary experience)

Name of Employer:

Name of Employer: Reason for Leaving:

Reason for Leaving: Job Duties: Job Duties: Position Held: Position Held: Dates from: Dates from: To: To:

Please tell us about any training you have received or courses you have attended which you feel are relevant to this position. (Please include specific dates)

Please tell us why you applied and give examples of things you have done that make you particularly suited to the job.

If you have any gaps in your career history, please include and explain these below.

Essential Experience.

Taking each individual element as stated on the job description, please outline with specific examples how you meet each of the criteria related to experience

Taking each individual element as stated on the person specification, please outline with examples how you meet as many elements as possible of the desirable criteria.

Desirable Experience.

Essential Personal Attributes.

Taking each individual attribute as stated on the person specification, please out-line with examples how you meet each of the criteria.

Under the Rehabilitation of Offenders (Exceptions) Order Northern Ireland, 1979, 3fivetwo Healthcare as a Provider of Health care is included in the list of excepted employers. As such, all criminal convictions may never be regarded as spent and must be disclosed when applying for a post in 3fivetwo Healthcare. It is necessary therefore to ask the following questions:

1. I declare that all the foregoing statements are true, complete and accurate.

2. I understand that if I give wrong information or leave out important information I could be dismissed if I take up this position.

3. I understand that if I take up this job I must have satisfactory references, health assessment and POCVA checks (if applicable).

4. I understand that I will be asked to provide formal identification and evidence of qualifications obtained. 5. I confirm that as far as I am know there are no medical reasons that would stop me from carrying out the

duties of this job.

6. I agree to you making any necessary enquiries during the recruitment and selection process. 7. I understand that canvassing will disqualify me from the selection process for this job.

8. I consent to the information I have provided being used within the context of the Data Protection Act 1998.

List below details of ALL charges, prosecutions, convictions, caution; bind over orders – even if they happened a long time ago. You must include any minor matters, any road traffic or motoring offences and any which may be pending

Please note that disclosure of a conviction does not necessarily debar any applicant from obtaining employment. Have you ever been convicted of any criminal offence?

Are you currently the subject of police investigation or have you any prosecutions pending?

CONVICTIONS/OFFENCES

PERSONAL DECLARATION

Yes No

How many periods of sickness have you had in the previous two years not related to maternity or disability?

How many days has each period lasted? Reasons?

Signature: Date:

Please name two referees one of whom should have knowledge of your present or most recent work as your Line Manager/Employer. (Relatives should not be named as referees). If you have worked in the HPSS/NHS, your last HPSS/NHS Line Manager/Employer must be one of these Referees

MEDICAL HISTORY

REFEREES

Name: Name:

Address: Address:

Post Code: Post Code:

Tel. No: Tel. No:

Email: Email:

Designation: Designation:

Please return completed application forms to:

Human Resources Department, 3fivetwo Healthcare, Channel Wharf, 21 Old Channel Road, Titanic Quarter, Belfast, BT3 9DE or email: [email protected].

3fivetwo Healthcare Group strives to be an Equal Opportunities Employer. We aim to ensure that our Equal Opportunities Policy is being followed and that unfair discrimination is not taking place. To help us monitor the effectiveness of this policy, we would be grateful if you would complete this attachment. The information

provided will be held in confidence and used for statistical purposes only. It will not be seen by those involved in the assessment of your application.

I have a Protestant Community background

White

Black African Mixed ethnic group (please state):

Please indicate your sex by ticking the appropriate box: Please state your Date of Birth:

Please state your Nationality:

Please indicate your race or colour or ethnic or national origins:

Male Female

I have a Roman Catholic Community background

Irish Traveller

I have neither a Protestant nor a Roman Catholic Community background

Pakistani

Private and Confidential

Community Background:

Sex: Age:

Racial Group:

Ethnic Origin:

Reference Number (Office only)

Any other ethnic group (please state):

Black Other Chinese

Black Caribbean Indian

Bangladeshi

EQUALITY MONITORING FORM

Under the Disability Discrimination Act 1995 a person is considered to have a disability if s/he has a physical or mental impairment which has a substantial and long-term adverse effect on his/her ability to carry out normal day to day activities.

Do you consider yourself to have a disability?

If you answered “yes” please state the nature or effects of your disability.:

Yes No

Disability:

Yes

Yes

If yes, please indicate who you look after No

No

Please indicate your sexual orientation by ticking the appropriate box:

Heterosexual Bi-Sexual Gay/Lesbian

Sexual Orientation:

Are you married or in a civil partnership?

Do you have dependants or caring responsibilities for family members or other persons? Marital Status / Civil Partnership Status

DEPENDANTS/ CARING RESPONSIBILITIES: