Hospiscare

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Section 1: Personal Details

First Name *

Last Name *

Email Address *

Mobile Number *

Do you currently work for us? *

Address Information

Street Address *

City *

County *

Country *

Postcode *

Section 2: Education & Professional Qualification

New Education History

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Institution Attended *

Date From *

Date To *

Please provide details of courses and grades received along with their relevant dates *

Section 3: Job History

Starting with your most recent employer, please provide details of your employment history. In the case of your most recent role, please also provide details of your reason for leaving.

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Employer Name *

Job Title *

Salary *

Date From *

Date To *

Please detail your role and responsibilities *

Section 4: Volunteer Work

Please give details of any training and development courses or non-qualifications courses which support your application. Include any on the job training as well as formal courses.

Give brief description of any voluntary work that you might have undertaken

Employer name

Brief outline of duties

Dates from-to (month/year)

Section 5: Supporting Statement

Tell us succinctly in no more than 2 pages why you are applying for this post.

Please read the job description and person specification provided. Using examples, show how your knowledge, skills and experience meet each of the essential criteria for the role.

Supporting Statement below:

Section 6: References

Referee 1

Name *

Email Address *

Contact Number *

Relationship to you *

Permission to contact * Yes No

Referee 2

Name *

Email Address *

Contact Number *

Relationship to you *

Permission to contact * Yes No

Section 7: Equal Opportunities

STRICTLY PRIVATE & CONFIDENTIAL

HOSPISCARE EQUALITY AND DIVERSITY MONITORING FORM

Completion of this form is required. The completed form will be held by our Human Resources Department in line with data protection regulations for monitoring reasons only.

THIS FORM DOES NOT CONSTITUTE PART OF THE SELECTION PROCESS AND IS NOT SEEN BY THE SHORTLISTING MANAGER OR SELECTION PANEL.

No job applicant, employee or volunteer shall be treated less favorably on the grounds of age, political belief, sex, sexual orientation, disability, marital status, race, nationality, ethnic origin, religion or belief, social class or offending background that does not create a risk to vulnerable groups.

The equal opportunity culture will be pursued in a positive spirit at all levels in order to ensure every individual receives treatment which is fair and equitable. Selection of candidates for either paid or voluntary work will be made only on the basis of the requirements of the job and on relevant personal merits. Hospiscare will not permit any job applicant, employee or volunteer to be placed at a disadvantage by requirements or conditions which have a disproportionately adverse effect on him or her, but which cannot be shown to be relevant to the specific job requirements.

For Equal Opportunities monitoring purposes only, please complete the form below:

To which gender identity do you most identify?

What is your age range?

Relationship Status

What is your nationality?

What is your ethnicity? (Please choose the most appropriate option to indicate your cultural background)

Other (please specify)

What is your religion or belief?

Other (please specify)

Do you consider yourself to have a disability as defined in the Disability Discrimination Act (1995)?

If you have a medical condition, the Disability Discrimination Act (1995) requires employers to make reasonable adjustments to the job content or working environment. To achieve this, we need to know whether you are covered. Definition of Disability: “A physical or mental impairment which has a substantial and long-term effect on a person’s ability to carry out normal day-to-day activities in a non-work environment.”

What is your sexual orientation? (As per the Employment Equality (Sexual Orientation) Regulations (2003))

Other (please specify)

Pregnancy and Maternity: Maternity is defined in the Equality Act as the 26 weeks after giving birth. Please select the option which describes your circumstance:

There are 6 million carers in the United Kingdom and nearly one in eight workers are carers. With an ageing population and an expected increase of 60% of carers in the next 30 years, we would like to monitor the number of people with caring responsibilities.

Do you have caring responsibilities?

Other (please specify)

Disability

This Act protects people with disabilities from unlawful discrimination. The Disability Discrimination Act defines a disabled person as someone who has a physical or mental impairment which has a substantial and long-term adverse effect upon your ability to carry out normal day-to-day activities.

We guarantee to interview anyone with a disability whose application meets the minimum criteria for the post. By “minimum criteria” we mean that you must provide us with evidence in your application form which demonstrates that you generally meet the level of competence required for the post, as well as meeting any of the qualifications, skills or experience defined as essential.

Do we need to make any specific arrangements for you to attend the interview? *

If yes please give details:

Rehabilitation of Offenders Act 1974

There are a number of posts and professions that are exempt from the provision of the Rehabilitation of Offenders Act 1974. These include posts where, in the normal course of their duties, successful applicants will have access to vulnerable adults. If the post you have applied for falls within the above category, it will be exempt from the provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act (Exemptions Order) 1975. Therefore I understand that the declaration will include details of criminal convictions, cautions, reprimands and final warnings and any other information that may have a bearing on my suitability for the post.

Applicants are therefore not entitled to withhold any information about convictions which for other purposes are ‘spent’ under the provisions of the Act and in the event of employment; any failure to disclose such convictions could result in dismissal or disciplinary action by Hospiscare. Any information given will be confidential and will be considered only in relation to posts to which the order applies.

Do you have any convictions that are unspent under the Rehabilitation of Offenders Act *

If yes please give details:

Section 8: Declaration

I confirm that the information I have given on this form is correct and complete, and that misleading statements may be sufficient for cancelling any agreements made. I understand that, in the event of job offer, I will be required to make a confidential declaration in respect of my state of health. I confirm