Position Applied For s4

If posting this application, please send to: Julie Beech HR Department Acorns Children’s Hospice Drakes Court Alcester Road Wythall B47 6JR

Alternatively, email your application to [email protected] Further instruction on completing this application form can be found online at www.acorns.org.uk

Confidential Application for Employment Position applied for:

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 Details Please start with current or most recent employment and then work backwards. 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.

Date from/to Employers name Job title Responsibilities and duties Reason for (month/year) and address Salary* (please be explicit) leaving: Notice period in current job:

Gaps in your employment – please provide information of any gaps in employment. From To Reason (month/year) (month/year)

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.

Criminal Convictions Because of the nature of the work for which you are applying, the post is excepted 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 Criminal Records Bureau Disclosure service to help assess an applicants 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.

References: Please give the name, address and position of two referees we may contact (not relatives or personal friends). 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.

May we approach your present employer for a reference prior to any conditional offer of employment Yes No 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.

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?