Available Start for: Date: Hospiscare Job Application Form

1 1 Post Applied for: Available Start date : Hospiscare Job Application form It is important that you read the job description before completing this Application form . Please complete this form fully using black ink or type. CVs are not accepted. applications received after the closing date will not normally be considered. Section 1 Present Employment Current or most recent employment Job Title: Line Manager s Name & Job Title: Employer s Building No & Address: Employer s Postcode: Employer s Telephone No: Hours worked: Dates Employed: From To Notice Period: Current Salary plus Benefits: Key Duties: What is your reason for leaving: Will you continue in any other employment, should you be offered this appointment? Yes No 2 If yes what is the other employment Section 2 Previous Employment Starting with the most recent first, please give details of jobs held including part-time and unpaid work.

2 Please give details of all previous jobs since leaving full time education. Full details should be given for any period not accounted for by full time employment, education or training ( unemployment, voluntary work, raising a family, part time work and working overseas). Name of Employer Job Title and Main Duties Reason for Leaving and Length of Employment date : From To date : From To date : From To date : From To date : From To date : From To 3 Section 3 Education Qualifications obtained from Schools, Colleges and Universities. Please list highest qualification first: College or University Course Qualifications and grades obtained School Subjects Qualifications and grades obtained Section 4 Professional, Technical or Management Qualifications Please give details: Professional/Technical/ Management Qualifications Course Details Name/Address of Institution Membership of any Professional / Technical Associations- Please state level of Membership: 4 Section 5 Training and Development Please give details of any training and development courses or non-qualifications courses which support your Application .

3 Include any on the job training as well as formal courses. Title of Training Programme or Course date of course Duration of Course Section 6 Voluntary Work Give brief description of any voluntary work that you might have undertaken Name and Address of organisation Brief outline of duties Dates from-to (month & year) 5 Section 7 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. 6 7 Section 8 Equality and Diversity Monitoring form 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 linewith data protection regulations for monitoring reasons only.

4 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 favourably 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.

5 8 For Equal Opportunities monitoring purposes only, please complete the form below: THE INFORMATION YOU SUPPLY ON THIS form WILL BE TREATED IN CONFIDENCE. Surname Forename(s) Previous or other name Preferred Name House Number Address Postcode NI Number (9 Digits) Day time telephone No Evening telephone No Email Do you hold a driving Licence? Full Provisional None Do you have any motoring convictions? Yes No If Yes please specify Gender Male Female Ot her Prefer not to say Marital Status Married Single Divorced Widowed Co -habiting Civil Partnership Prefer not to say Sexual Orientation Bi Sexual Gay Heterosexual Lesbian Pr efer not to say date of Birth 9 What is your Ethnic Group? Choose ONE section from A to E, then tick the appropriate box to indicate your cultural background. A. WhiteD. Black or Black BritishWhite UK Black Caribbean Irish Black African White non-UK Any other Black background (please give details): Any other White background (please give details): or other ethnic groupWhite & Black CaribbeanChinese White & Black AfricanVietnamese White & AsianAny other ethnic background (please give details): Any other Mixed background(please give details):C.

6 Asian or Asian do not wish to provide thisinformationIndianPakistaniBangladesh iAny other Asian background(please give details):I would describe my religion as (please tick box): Buddhism Hinduism Jewish Muslim Sikhism Other No Religion Christianity Prefer not to say 10 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.

7 Do you have a disability which is relevant to your Application ? Yes No If yes please give details: We will try to provide access, equipment or other practical support to ensure that people with disabilities can compete on equal terms with non-disable people. Do we need to make any specific arrangements for you to attend the interview? Yes No If yes please give details: 11 How did you learn of this vacancy (please tick box)? Where did you see this vacancy advertised? Newspaper/ publication Hospiscare noticeboard Job Centre National Newspaper Hospiscare Website Friend Other: Please state 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.

8 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?

9 Yes No If yes please give details: 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 being shortlisted for interview, I will be required to make a confidential declaration in respect of my state of health. Signature: date : 12 For Office Use Only: Start date .