The Information Supplied in Part 1 Will Not Be Used for Selection Purposes

Partner Application Form

Please complete this form and email it to [email protected]. Please note that we can’t accept handwritten or postal application forms.

Part 1a The information supplied in part 1 will not be used for selection purposes.

Partner Role applied for: Legal Assessor Profession & Modality (where applicable): Are there dates when you cannot be contacted, in relation to this application?

About you First Name Surname

Title Mr/Mrs/Miss/Dr/Prof

Home address Work address

Home/Mobile Home Work telephone numbers telephone Mob number E-mail

Please ensure that you supply a valid accessible email address as we will communicate with you via email throughout the recruitment process. Your right to work Are there any restrictions on your rights to reside/work in the United Kingdom? Yes

If yes, please specify: No Your registration

Are you currently registered with the Health and Care Professions Council? Yes No

If yes, please state your HCPC registration number:

Equality Act 2010

Under the Equality Act 2010 a person has a disability if they have a physical or mental impairment and the impairment has a substantial and long-term adverse effect on their ability to perform normal day-to- day activities.

Do you consider yourself to have a disability? Yes No

If you answered yes to the above question, please give details:

Disabled applicants who meet the essential criteria in the person specification will be shortlisted for interview. If you need us to make particular arrangements for completing the application form and/or attending an interview, please contact the Partners Team (on 0207 840 9737/776 or at the above address) separately.

The Health and Care Professions Council is working towards equality of opportunity in employment. To this end, the front sheet of your application, the Equal Opportunities and Diversity Monitoring form and any other identifying information will be detached prior to submitting applications forms for shortlisting Part 1b – Any information declared in sections 1b – 1d will not be used for competitive selection purposes but will be reviewed by the partners department and a manager in the relevant user department, prior to an interview invite being issued.

Conflicts of interest and other material information

In confidence A person appointed to a public body could find that matters or incidents which previously attracted no attention could become matters of legitimate public interest when the person concerned holds a public appointment. Information which might be relevant could include either specific events such as those covered below or prominent activities, for example in voluntary organisations. The following sections ask for information which may be relevant in this context. All information given will be treated in the strictest confidence.

Have you:

1 Ever been convicted of any criminal offences or accepted a caution in the UK (other than minor motoring offences) which are not spent in accordance with the Rehabilitation of Offenders YES NO Act 1974, or of any offences elsewhere which if committed in England and Wales would be criminal offences?

2 Ever been the subject of disqualification from the practice of a profession in the UK or elsewhere which remains in force; or are you the subject of any proceedings which could lead to such YES NO a disqualification?

3 Any outstanding charges? YES NO 4 Been declared bankrupt in the past 10 years? YES NO 5 Been dismissed from any office or employment in the past 10 years? YES NO

6 Ever been disqualified from acting as a Company Director or in the conduct of a company? YES NO

7 Ever been trustee of a charity? YES NO 8 Ever been a director, partner or manager of a company which has gone into liquidation, receivership or administration? YES NO

9 Any other facts to declare which you feel could be raised publicly in the future relating to your suitability to hold the appointment for which you are being considered? YES NO Examples should include anything that could be presented as a conflict of interest. If you have answered YES to any of the questions above, please give details in the space below and continue on a separate sheet if necessary.

Part 1c - Other business interests

Please note that the council has accepted proposals which reinforce the rules inspired by the Nolan Committee on the handling of public body business and have decided to make the appointment of new members subject to stricter conditions on members’ private interests in the market sectors relevant to the work of the body concerned.

If you have answered YES to questions 1-2, please give details:

1 Of which you are, or have been, during the previous 10 years a director or partner? YES NO 2 Of which you own more than 50%, whether or not you are a director or partner? YES NO

Name of the body and principal activities

3 Do you, or your spouse or partner, hold direct shareholdings in market sectors linked to the work of the Health and Care Professions YES NO Council? 4 Are you, or your spouse or partner, directors of commercial firms in those market sectors? YES NO 5 Do you, or your spouse or partner, receive any retainer from commercial firms in those market sectors? YES NO

If you have answered YES to questions 3-5, please give details:

Name of the commercial firm and principal activities

Where pecuniary interest is declared, you are asked if you are willing to forego it.

If pecuniary interest is declared are you, or your spouse or partner, willing to forego it for the period of appointment? YES NO Part 1d - Significant political activity

The Nolan Committee on standards in Public Life recommended that all candidates should declare any significant political activity. Political activity information will be used for monitoring purposes only and will not determine your suitability for appointment. If your application is successful, this information will become part of the public record.

In the last five years, have you undertaken any significant political activity? (This should include activities that are a matter of public record i.e. office holding in, public speaking in support of, or candidate on behalf of, any political party (or affiliated body) which fields candidates at local or general elections in any part of the UK or in elections to the European Parliament.

YES NO

If YES, please give details below: Declaration

I undertake to advise the Council of any other information relevant to an assessment of suitability as a public appointee and to report and significant future change to the information I have provided on this form.

I certify that if appointed to a position at HCPC, I will inform the council of any change of circumstance which would result in a YES answer having to be given to any of the questions in parts 1b, 1c, 1d.

I confirm that the information given on this form is complete and true, to the best of my knowledge. I understand that if I am appointed and the information I have provided is subsequently found to be untrue, then my tenure of office may be terminated.

Signed:

Name in block capitals:

Date: Part 1e

Full Name

Position held Organisation and relationship Address Postcode References

Telephone E-mail

Please give the names and addresses of two professional referees They should be a Line Manager or someone in a position of responsibility who can comment on your work experience. References should be from your: Two most recent employers (where possible) and should Cover your last three years of employment. If your two referees do not cover the last 3 years of employment, please provide a 3rd professional referee. Referees will not be contacted until a preliminary job offer has been made or without your consent.

Full Name

Position held Organisation and relationship Address Postcode

Telephone E-mail

Full Name

Telephone E-mail

Full Name

Telephone E-mail Data Protection

The information on this application form will be held securely, both manually and electronically by the HCPC and will not be divulged to anyone outside the organisation. Information on unsuccessful candidates will be held for a period of six months.

We reserve the right to verify the information you have provided and seek information from other sources.

Declaration

Please note: You should complete all of parts 1 and 2 of the application form before completing this section.

I declare that all the information given on this form is, to the best of my knowledge, complete and correct. I understand that if I am employed and any of the information I have provided is false, my contract may be terminated.

I certify that to the best of my knowledge, the information given on this form is correct.

Signature: Date

Please note, if you are sending this application form via email you will be required to sign the form if you are invited to an interview. Recruitment Monitoring

Where did you hear about this role?

HCPC Website

Twitter/ Facebook

Other External Website Please state which site:

HCPC InFocus

External Publication Please state name of publication:

Word of mouth

Please state where: Part 1f - Equal Opportunities and Diversity Monitoring Form

Thank you for applying for a partner vacancy at the HCPC. The purpose of this form is to help us monitor and improve our standards of recruitment practice.

Any information gathered for statistical analysis will be used anonymously and will not be used to assess or score your application.

The HCPC is committed to equal opportunities and reflecting the diversity of the public. To monitor our recruitment process we collect diversity data on all applications, which is stored separately from the rest of your application and is not seen by any short-listing or interview panel. It is used to produce statistics so that we can analyse the diversity profile of those applying to the HCPC and meet the obligations of our Equality and Diversity Scheme.

Date of Birth Prefer not to disclose (dd/mm/yyyy) Gender Male Female Transgender Prefer not to disclose

Please describe your marital status

Single Married Divorced Prefer not to disclose Civil Partnership Partner Widowed

Do you have dependent children?

Yes No Prefer not to disclose

If yes, please indicate number: ______

Please select the option which best describes your sexual orientation

Lesbian Heterosexual Bisexual Gay Prefer not to disclose Please indicate which of the following describes your ethnic group Asian Chinese Bangladeshi Chinese Indian Any other Chinese background Pakistani Mixed Any other Asian background Asian & White Black Black African & White African Black Caribbean & White Caribbean Any other mixed background Any other Black background Other Ethnic Group White Any other ethnic group British Undisclosed Irish Prefer not to disclose Any other White background

If any other background, or any other ethnic group chosen, please specify: ......

Please indicate your religion or belief

Atheism Islam Prefer not to disclose Buddhism Jainism Other (please specify) Christianity Judaism …………………………….. Hinduism Sikhism

Do you consider yourself to have a Yes No Prefer not to disclose disability?

Please state the type of disability which applies to you. People may experience more than one type of disability, in which case you may indicate more than one.

Physical Learning Disability/Difficulty Sensory Long-standing illness Mental health condition Other (please specify if you wish) …………………………………..………………………………………………………………. Part 2 The information supplied in Part 2 will be used for selection and will be available to the shortlisting and interview panel. Please note: We do not accept CV’s as an accompaniment to or in place of an application form. If there is insufficient space to detail your relevant employment/ business activity, please use the continuation sheet at the end of this form.

Your employment history Current Employment Name and address of Postcode employer

Job title Date of appointment Present salary and grade

Please give a brief description of your duties and responsibilities

Previous employment (Please state most recent first) Name and address of employer From To Position held Reason for leaving

Your education and training School, College or University From To Qualification Subject

Additional qualifications

Awarding Body Qualification Year award ed

Membership of professional bodies

Professional Body Membership status Year awarded

Training and short courses

Please state any non-qualification training you have undertaken that is relevant to the post for which you are applying. Training body or Course/ development type Date Organisation

Please refer to the Information for Application and Guidance Notes before completing this section.

We will only use the information provided in the below sections to assess your application. You have a maximum of 300 words or 2,000 characters per section.

Reason for Application

Please state your reason why you wish to apply for this role (maximum 300 words or 2,000 characters).

Advising effectively

Please refer to the ‘Information for Applicants’ and provide specific examples below how you demonstrate the competency (maximum 300 words or 2,000 characters).

Working with others Please refer to the ‘Information for Applicants’ and provide specific examples below how you demonstrate the competency (maximum 300 words or 2,000 characters).

Exercising judgement

Demonstrating and building knowledge Please refer to the ‘Information for Applicants’ and provide specific examples below how you demonstrate the competency (maximum 300 words or 2,000 characters).

Managing work efficiently

Communicating effectively