If Posting This Application, Please Send To

Confidential application for employment

Position applied for: If posting this application, please send to:

Caroline Tyler, HR Advisor Acorns Children’s Hospice, Drakes Court, Alcester Road, Wythall, B47 6JR Tel: 01564 825033

Alternatively, email your application to [email protected]

Personal details

Title: (Please specify) Mr  Mrs  Miss  Ms  Other:

Last name:

First names(s):

Address:

Post Code:

Telephone number: Private:

Business: Mobile:

Contact email address:

NI number:

Do you hold a current driving licence?  Yes  No

Do you have the use of a motor car?  Yes  No

Do you need a work permit for employment in the UK?  Yes  No

Please list any foreign languages spoken or written, indicating degree of fluency:

If offered this position, will you continue to work in any other capacity? (Give details):

Membership of Professional Bodies (include NMC registration where applicable):

Name: Renewal/ expiry date:

Membership/status: Number:

Name: Renewal/ expiry date: Membership/status: Number:

Career history

Previous employment: Please include any previous experience (paid or unpaid), starting with the most recent first. Include a note of all periods of unemployment; travel etc. in the space provided so there are no gaps in the record. *Please specify separately under salary the cash values of any bonuses/allowances or benefits. Current or most recent employer

Name of Employer:

Address:

Post Code:

Position held:

Date started: Date of leaving:

Reason for leaving:

*Salary on leaving: Notice period:

Brief description of duties:

Previous employer

Name of Employer:

Address:

Post Code:

Position held:

Reason for leaving:

Brief description of duties: Previous employer

Name of Employer:

Address:

Post Code:

Position held:

Reason for leaving:

Brief description of duties:

Previous employer

Name of Employer:

Address:

Post Code:

Position held:

Reason for leaving:

Brief description of duties: Gaps in your employment

Please provide information of any gaps in employment.

From (month/year) To (month/year) Reason

References

Please give the name, address and position of two referees we may contact (not relatives, personal friends or employees of Acorns). At least one of these should be from your last employer.

Name: Name: Job title: Job title: Organisation: Organisation: Address (in full): Address (in full):

Telephone no: Telephone no: Email: Email:

May we approach your present employer for a reference prior to any conditional offer of employment

 Yes  No

Criminal Convictions Because of the nature of the work for which you are applying, the post is exempt from the Rehabilitation of Offenders legislation. You must still declare any cautions, convictions or reprimands and tell us if there are any proceedings outstanding against you. In the event of employment failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relevance to an application for positions to which the Rehabilitation Offenders Act 1974 (Exceptions) Order 1975 applies. Details of declaration of criminal record:

Acorns Children’s Hospice Trust use the Disclosure and Barring Service to help assess an applicant’s suitability for work involving contact with children. A Disclosure (police check) will be requested in the event of a successful application for any staff who have contact with the hospice.

Additional information

Please give your reasons for applying for this post and tell us how your experience, skills and qualifications meet the requirements of the post. Please supply any additional information which you may feel might support your application. You may draw on experiences from your personal life such as voluntary work or work in the home.

You may provide additional continuation sheet/s, which clearly states your name and the position you are applying for. Education, training and qualifications

School Examination Schools attended from age 11 (Subjects/results)

Further education Type of training Qualifications Place of education

Special courses / other qualifications Examination results and dates Declaration

I declare that all information given by me in this document is correct and will form part of my contract of employment should I be offered a post with Acorns Children’s Hospice Trust or any associated company. I agree to the organisation verifying the information given. Any false statement may be sufficient cause for rejection or, if employed, dismissal without notice. I also confirm that I am not disqualified from working with children and understand that an Enhanced Disclosure will be sought in the event of a successful application for posts which have contact with the hospice.

I understand and agree that data contained in the application form will be used and processed for recruitment purposes. I understand and agree that should I become an employee, the information will also be used for employment related purposes and I agree to Acorns Children’s Hospice Trust holding and processing this information in line with the Data Protection Act.

Signed: ……………………………………………………………………… Date: …………………………….

Please tick this box if applying electronically

 I confirm that all the information provided in this application is accurate and correct and has been completed by myself. I acknowledge that I have read and agree with the above declaration, and the policies that accompany this application. Equal opportunities monitoring form – confidential

Acorns Children’s Hospice Trust aims to offer equal opportunity in employment. To assist us with monitoring for this policy and for that purpose only, please provide the details below. This information WILL NOT be taken into account in selection. It will be separated on receipt and treated as confidential.

Date of Birth:

Do you consider yourself to have, or have had a disability?  Yes  No

Gender: Male Female  

Nationality

How would you describe your ethnic origin? (As defined in 2001 census).

White: Mixed:

 British  White & Asian

 Irish  White & Black Caribbean

Scottish  White & Black African 

Welsh  Any other mixed background 

Any other white 

Asian, Asian British, Asian English, Black, Black British, Black English, Asian Scottish, Asian Welsh: Black Scottish, Black Welsh:

 Indian  Caribbean Pakistani  African 

Bangladeshi  Any other Black background 

Any other Asian background 

Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh, or other ethnic group:

 Chinese

Any other Ethnic background 

Where did you see this post advertised?