Application for Employment s66

C O N F I D E N T I A L Application for Employment Post for which you are applying: Closing date: Practice Manager Friday 21 October 2016

PERSONAL DETAILS First Title: Mr/Mrs/Miss/Ms: Names: Surname: Address: Telephone Numbers Home: Mobile: Business: Postcode: Do you hold a full licence to drive a car? YES/NO Do you require a Work Permit to be employed Expiry date of current Permit: In the United Kingdom? YES / NO National Insurance No: Are you disabled within the meaning of the Disability Discrimination Act? YES/NO

EDUCATION AND TRAINING FROM TO QUALIFICATIONS YEAR(S) OBTAINED SCHOOLS ATTENDED (State subjects and levels) General Education

UNIVERSITY/COLLEGE/INSTITUTE FROM TO QUALIFICATIONS/COURSES YEAR(S) OBTAINED TRAINING CENTRE

CURRENT STUDIES FROM TO EXAMINATION DATES

ADDITIONAL TRAINING – details of any specialist training not covered above

Dr Cross & Partners, Greenway Community Practice, Greystoke Avenue, Southmead, Bristol BS10 6AF Tel: 0117 959 8939 VAT Reg No: 870 0820 43 Fax: 0117 959 MEMBERSHIP OF PROFESSIONAL BODIES

Body: Membership Status: Date:

STATE REGISTRATION

Body: Registration No: Date:

CURRENT OR MOST RECENT EMPLOYMENT

Post held: Salary and Grade:

Date appointed: Date left:

Reason for leaving (where applicable):

Employer’s name and address:

Location of employment (if different from above):

Summary of duties and responsibilities, including position in organisation structure, staff supervised etc:

PREVIOUS EMPLOYMENT over last 10 years POST HELD NAME & ADDRESS OF EMPLOYER FROM TO REASON FOR LEAVING/CHANGE

If necessary continue on separate sheet

Dr Cross & Partners, Greenway Community Practice, Greystoke Avenue, Southmead, Bristol BS10 6AF Tel: 0117 959 8939 VAT Reg No: 870 0820 43 Fax: 0117 959 SUPPORTING INFORMATION In support of your application you are invited to give a concise account of your relevant experience and skills and why you think you should be considered for this post.

If necessary continue on separate sheet

SPECIAL ACTIVITIES OR INTERESTS RELEVANT TO THE POST

Dr Cross & Partners, Greenway Community Practice, Greystoke Avenue, Southmead, Bristol BS10 6AF Tel: 0117 959 8939 VAT Reg No: 870 0820 43 Fax: 0117 959 REFERENCES Please give the names and addresses (and telephone numbers if possible) of two referees, one of whom should be your present or most recent employer. NB: Referees will automatically be approached if you are short-listed for interview, unless you specifically indicate otherwise.

1. 2. Name: Name: Position/Capacity in which Position/Capacity in which you know this person: you know this person: Address: Address:

Tel: Tel: May we approach them prior to interview? 1. YES/NO 2. YES/NO (Referees will only be contacted if you have been requested to attend for interview. References are confidential and GPs will not therefore enter into any discussion with candidates with regard to their contents)

MEDICAL INFORMATION You will be required to complete a health questionnaire and may also undergo a medical examination. No confirmation of employment can be made without this health check.

REHABILITATION OF OFFENDERS ACT This post is NOT protected by the Rehabilitation of Offenders Act 1974. You are therefore required to disclose information about all convictions in a court of law, no matter when they occurred, or if they led to a conditional discharge. In the event of employment, failure to disclose all previous convictions will result in dismissal. All information will be treated in confidence and will only be taken into account when absolutely necessary.

Have you ever been convicted in a court of Law YES/NO

If YES please provide full details in the space below, or under separate cover.

DATA PROTECTION ACT 1998 Any information supplied may be held on paper or computer files and therefore falls within the provision of this Act.

How did you learn about this post?

I declare that, to the best of my knowledge, the information given above is correct. If appointed I understand that deliberate omissions, incorrect statements, canvassing of partners in connection with this application should render me liable to dismissal. I understand that if this post is one which has substantial access to children and/or vulnerable adults, I give my permission for the relevant checks to be completed with the Criminal Records Bureau.

Signature: Date:

This form should be returned by email to: Mr Peter Riordan, Practice Manager, at [email protected]

Dr Cross & Partners, Greenway Community Practice, Greystoke Avenue, Southmead, Bristol BS10 6AF Tel: 0117 959 8939 VAT Reg No: 870 0820 43 Fax: 0117 959