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1 Ref no. office use only: Post applied for: Location: Before completing this form please carefully read the accompanying guidance notes and job description. You can return the form by or by post. If you are completing the form by hand please write clearly in black ink. Please note that CVs will not be accepted. Please note that section 1,2,3,4 will be treated in the strictest confidence and will be detached before applications are short listed. This application form is available in other formats. Please contact the recruitment team for further advice by to: 1. Personal details Title: Forenames: Surname: Address line 1: Address line 2: Address line 3: Address line 4: Postcode: address: Home telephone: Mobile telephone: Work telephone: (Please only provide if we can call you on this number) 2. Asylum and immigration legislation right to work in the UK It is a requirement under the Asylum and Immigration Act (1996) that we do not employ someone who does not have the right to work in the UK. If you are successful in being offered this post, it will be conditional on you providing evidence of eligibility to work in the UK. Are you a UK Citizen? Are you an EU Citizen? 1

2 If yes, from which country? If no to both the above do you have indefinite leave to remain in the UK? If no to the all the above what visa do you hold and when does it expire? National Insurance Number: If required could you produce one of the following documents? 1. A document showing your name and National Insurance number from a previous employer or the HM Revenue & Customs or the Benefits Agency or the Contributions Agency or the Employment Service. 2. A passport confirming British Citizenship or a national of the European Economic Area. 3. A birth certificate confirming birth in the UK or the Republic of Ireland. 4. A letter from the Home Office confirming that you are allowed to work in the UK. 3. Equal opportunities monitoring information The London Ambulance Service NHS Trust recognises and actively promotes the benefits of having a diverse workforce. We are committed to treating all employees with respect and dignity regardless of age, disability, gender, race, religion or belief or sexual orientation. To help us ensure we receive applications from all sections of society please complete this equal opportunities monitoring form. Any information you give us will be treated in the strictest confidence and will be detached before applications are short listed. Age Date of birth: Disability Do you consider that you have (or have had) a disability? The Disability Discrimination Act defines disability as A physical or mental impairment which has a substantial and long-term effect on the person s ability to carry out normal day-to-day activities If yes, please state the nature of the disability: If you are invited for an assessment/interview, are there any reasonable adjustments you would like us to make to the interview or selection process? 2

3 If yes, Would you like to be considered for the guaranteed interview scheme (If you meet the essential requirements of the person specification, you will be automatically put through to the next stage of the recruitment process) Gender Female: Male: Other Prefer not to say Religion or Belief Baha i Buddhism Christianity Hinduism Humanism Islam Jainism Judaism Rastafarianism Sikhism Zoroastrianism If other please state religion or belief: Prefer not to say: Sexual Orientation Bisexual person Gay man Heterosexual/straight person Lesbian/Gay woman Other sexual orientation please state: Prefer not to say Ethnicity The categories used are those recommended for all NHS employees and are based on the 2001 census. Please tick the box next to the category which you feel best describes your ethnicity. Asian or Asian Background Bangladeshi Indian Pakistani Other Ethnic Groups Chinese White British 3

4 Any other Asian Background Black or Black British African Caribbean Any other black background Mixed/Dual Heritage White & Asian White & Black African White & Black Caribbean Irish Any other white background Any other ethnic group 4. Criminal convictions (Please refer to guidance notes on criminal convictions) If you have a criminal conviction, then this will be reviewed once the form has been short listed and further information may be sought before proceeding to the next recruitment stage Have you ever been convicted of a criminal offence? If you are sending this form by please print your name above and mark X in the following box to certify that the information is correct to the best of your knowledge Signed: Date: Date Court Offence Sentence 4

5 Post applied for: Location: 5. Driving licence If the post you have applied for includes driving duties please provide the following details: Do you hold a full manual UK driving licence that covers categories C1 or D1? Category C1 Category D1 Do you have the use of a vehicle? 6. Driving experience If the post you have applied for includes driving duties please provide the following details: How many years have you held a licence? How many years have you actually driven? Has your licence ever been endorsed? Has your licence ever been suspended? If yes to either question, please give full details including dates and codes of convictions and penalty points: If you have experience of driving heavy vehicles, please state type of vehicle and nature of experience: If you are experienced in driving in London traffic, which areas or traffic routes are you most familiar with? The information provided on the following section of the form will be used for assessing candidates against the criteria of the post. Use additional sheets for any information you cannot record in this section. 5

6 7. Education (secondary, further, higher) Establishment (school, college etc.) Date/s from Date/s to Qualifications/grade 8. Job related training Courses of study/institute Date/s from Date/s to Standard or level achieved 9. Employment history Current employer Employer s name Address line 1 Address line 2: Address line 3: Address line 4: Postcode: Post held: Date appointed: Notice period: For reference purposes Manager s name: Telephone number: 6

7 If you do not wish us to approach your current employer for a reference without your authority, please mark X here Please note that references will be sought from current and previous employers as appropriate and your offer of employment will be subject to satisfactory references. Previous employer (most recent first) Dates From/to Employer s name, full address and type of business Position held Reasons for leaving 10. Reasons for applying for this post, experience and personal skills (Refer to guidance notes) Use additional sheets for any information you cannot record in this section. 7

8 8

9 11. Recruitment information How did you learn about this post? If other, please state where you heard: Have you previously applied for any other position with the London Ambulance Service NHS Trust? If yes, post applied for: Date of application: Outcome of the application: 12. Sickness and absence Have you been absent from work/college/school due to sickness during the last three years? If yes, please give details (continue on a separate sheet if necessary) Date/s Number of days Reason 13. Data protection best practice statement The London Ambulance Service (LAS) NHS Trust needs to collect essential personal data from potential employees in order to be able to complete the necessary processes for new starters. This includes information obtained from this form and from other parts of the recruitment process such as references. The information collected will be processed in accordance with the principles of the Data Protection Act Any information obtained will be kept securely and not passed to a third party unless legal obliged too. If you are concerned about any aspects of this then please contact the recruitment team. 9

10 14. Relationships/other interests Are you related to or do you have a close relationship with a London Ambulance Service NHS Trust Board Director or Manager of the Trust? If yes, please state : Name: Position: Relationship: 15. Job share Are you applying for a job share? If yes, do you have a job share Partner? 16. Independent Safeguarding Authority (ISA) Registration Are ISA registered? If yes please state ISA number: 17. Declaration I certify that the information given on this form is correct to the best of my knowledge. If you are sending this form by please print your name below and mark X in the following box to certify that the information you have given is correct to the best of your knowledge Signed: Date: Please return the form by to or alternatively you can print out the form and post it to London Ambulance Service, Recruitment Centre, St Andrew House, St Andrews Way, Devons Road, Bow, London, E3 3PA. If you are posting please ensure that you have the correct postage as applications received after the close date will not be accepted. 10

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