Employment application


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NameEmployment application
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EMPLOYMENT APPLICATION
This form may not allow sufficient space for provision of the information requested, or other information you feel would be relevant to the application. If this is the case, please include additional sheets.
PERSONAL DETAILS:


Post applied for:


Where did you see the post advertised?


Surname:
Male/female:

First Name(s):



Address:




Postcode:

Telephone No: Daytime: Evening:
E-mail address:
Do you hold a current UK driving licence?
What would be your method of transport to work?


Are you legally eligible for employment in the UK? Yes / No (delete as applicable)
Do you require a work permit to work in the UK? Yes / No (delete as applicable)
Please note that prior to making an offer of employment, we are required by law to verify documentary evidence (and maintain copies for our files) regarding a candidate’s eligibility to work in the UK. This applies to all applicants regardless of nationality/origin.


Have you any criminal convictions, which you should disclose?
Yes / No (delete as applicable)

If yes please give dates and details.




CURRENT (OR MOST RECENT) EMPLOYMENT OR WORK EXPERIENCE


Title of Post


Name and Address of Employer






Postcode

Nature of Business

Date of Appointment



Salary and Grade/Scale



Period of Notice / Contract End Date


Summary of Duties Responsibilities





PREVIOUS EMPLOYMENT (most recent first - you may include unpaid work)

Please give a brief explanation of any periods of unemployment


Employer’s Name and Address

Title of Post Held

Salary and Scale

Date

From

Date

To

Reason for leaving



















EDUCATION AND QUALIFICATIONS (most recent first). Include details of any qualifications for which you are currently studying/expect to attain.


Schools, Colleges Universities or other Training organisations

From*

To*

Programme of study/examinations taken (with levels and grades)













* Inclusion of qualification dates is not compulsory
PERSONAL INTERESTS/HOBBIES




APPLICANTS WHO ARE PATIENTS OF FARNHAM DENE MEDICAL PRACTICE:
Farnham Dene Medical Practice considers that employing staff who are patients of the practice has significant disadvantages both to the patient and to the practice. Please note therefore that if your application is successful, you will be required to register elsewhere.

REFERENCES
Please give the name, address and telephone number of two people who would be willing to give you a reference. If you are currently or have recently been in employment, one of these should be your current or last employer. If not, a referee should be a person who can make a statement with regard to your character, e.g. a school or college teacher. Referees must not be members of your family or related to you in any way.


Name



Name


Job Title (if applicable)



Job Title (if applicable)


Address


Address


Postcode

Postcode

Telephone


Telephone


How does this person know you?

How does this person know you?




If required, may we take up reference before interview?

Yes / No (delete as applicable)






If required, may we take up reference before interview?

Yes / No (delete as applicable)




INFORMATION IN SUPPORT OF THIS APPLICATION



In your own words, describe the sort of work you think you would be asked to undertake if you were successful in getting this job:

Please use the space below explain why you would be a good applicant for the post, including any experience you have gained, skills you have to offer (for example, IT skills) and personal qualities. This may include work and voluntary/domestic activities (eg. school committees, charity work). Please relate your comments to the job description and advertisement.

Please continue on an additional sheet if necessary


APPLICANT’S DECLARATION
I hereby give my consent, in connection with this application, for all previous employers, educational institutions and references to be contacted to obtain and verify the accuracy of information provided by me in support of this application.
I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of the application or immediate termination of employment, whenever it may be discovered.
I understand that Farnham Dene Medical Practice is permitted to hold personal information about me as identified on this application form as part of its recruitment procedures and personnel records.
Note: Farnham Dene Medical Practice is an equal opportunities employer and does not unlawfully discriminate in employment. No information provided by the applicant will be used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by law.
Finally, please complete the monitoring information at Appendix 1.


Applicant’s signature:



Date:



This form should be returned to

Mrs Rabia Cody at

Farnham Dene Medical Practice, Farnham Centre for Health, Hale Road, Farnham, Surrey GU9 9QS


FOR OFFICE USE ONLY

Date application received:

Interview: Yes / No




Shortlist Yes / No

Notes on references:





APPENDIX 1 (all information provided with be treated in strictest confidence)
DISABILITY & HEALTH MONITORING INFORMATION

Do you have any disability or medical condition, which may affect your suitability for this post? Yes / No (delete as applicable)

If yes, please give details:



If required, would you be willing to undergo a medical examination?

Yes / No (delete as applicable)


Are there any reasonable working adjustments you would need us to make to accommodate your health? Yes / No (delete as applicable)

If yes, please give details:



Please note that Farnham Dene Medical Practice operates a non-smoking policy covering all practice premises

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