APPLICATION FOR EMPLOYMENT

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1 APPLICATION FOR EMPLOYMENT PLEASE COMPLETE IN BLACK INK INCORPORATING Reference Number: POSITION APPLIED FOR: PERSONAL DETAILS Title: Surname: First Name: Home Address: Post Code: Address: Contact Number: Do you hold a current clean driving licence?: EDUCATION DETAILS Please tell us about your education and any qualifications which you feel are relevant to the post. Type of Institution Subject studied Qualification Level Date obtained Are you a member of any Professional Body?: If yes please state name:

2 EMPLOYMENT DETAILS Please tell us about previous employment starting with the most recent (please include both paid and voluntary experience) Name of Employer: Dates from: To: Position Held: Job Duties: Reason for Leaving: Name of Employer: Dates from: To: Position Held: Job Duties: Reason for Leaving:

3 EMPLOYMENT DETAILS Please tell us about previous employment starting with the most recent (please include both paid and voluntary experience) Name of Employer: Dates from: To: Position Held: Job Duties: Reason for Leaving: Name of Employer: Dates from: To: Position Held: Job Duties: Reason for Leaving:

4 Please tell us about any training you have received or courses you have attended which you feel are relevant to this position. (Please include specific dates) Please tell us why you applied and give examples of things you have done that make you particularly suited to the job.

5 If you have any gaps in your career history, please include and explain these below. Essential Experience. Taking each individual element as stated on the job description, please outline with specific examples how you meet each of the criteria related to experience

6 Desirable Experience. Taking each individual element as stated on the person specification, please outline with examples how you meet as many elements as possible of the desirable criteria. Essential Personal Attributes. Taking each individual attribute as stated on the person specification, please outline with examples how you meet each of the criteria.

7 CONVICTIONS/OFFENCES Under the Rehabilitation of Offenders (Exceptions) Order rthern Ireland, 1979, 3fivetwo Healthcare as a Provider of Health care is included in the list of excepted employers. As such, all criminal convictions may never be regarded as spent and must be disclosed when applying for a post in 3fivetwo Healthcare. It is necessary therefore to ask the following questions: Have you ever been convicted of any criminal offence? PERSONAL DECLARATION 1. I declare that all the foregoing statements are true, complete and accurate. 2. I understand that if I give wrong information or leave out important information I could be dismissed if I take up this position. 3. I understand that if I take up this job I must have satisfactory references, health assessment and POCVA checks (if applicable). 4. I understand that I will be asked to provide formal identification and evidence of qualifications obtained. 5. I confirm that as far as I am know there are no medical reasons that would stop me from carrying out the duties of this job. 6. I agree to you making any necessary enquiries during the recruitment and selection process. 7. I understand that canvassing will disqualify me from the selection process for this job. 8. I consent to the information I have provided being used within the context of the Data Protection Act Are you currently the subject of police investigation or have you any prosecutions pending? List below details of ALL charges, prosecutions, convictions, caution; bind over orders even if they happened a long time ago. You must include any minor matters, any road traffic or motoring offences and any which may be pending Please note that disclosure of a conviction does not necessarily debar any applicant from obtaining employment.

8 MEDICAL HISTORY How many periods of sickness have you had in the previous two years not related to maternity or disability? How many days has each period lasted? Reasons? Signature: Date: REFEREES Please name two referees one of whom should have knowledge of your present or most recent work as your Line Manager/Employer. (Relatives should not be named as referees). If you have worked in the HPSS/NHS, your last HPSS/NHS Line Manager/Employer must be one of these Referees Name: Address: Name: Address: Post Code: Tel. : Designation: Post Code: Tel. : Designation: Please return completed application forms to: Human Resources Department, 3fivetwo Healthcare, Channel Wharf, 21 Old Channel Road, Titanic Quarter, Belfast, BT3 9DE or If you require any special assistance please do not hesitate to contact us.

9 EQUALITY MONITORING FORM 3fivetwo Healthcare Group strives to be an Equal Opportunities Employer. We aim to ensure that our Equal Opportunities Policy is being followed and that unfair discrimination is not taking place. To help us monitor the effectiveness of this policy, we would be grateful if you would complete this attachment. The information provided will be held in confidence and used for statistical purposes only. It will not be seen by those involved in the assessment of your application. Reference Number (Office only) Private and Confidential Community Background: I have a Protestant Community background I have a Roman Catholic Community background I have neither a Protestant nor a Roman Catholic Community background Sex: Please indicate your sex by ticking the appropriate box: Age: Please state your Date of Birth: Male Female Racial Group: Please state your Nationality: Ethnic Origin: Please indicate your race or colour or ethnic or national origins: White Black Caribbean Indian Irish Traveller Black Other Bangladeshi Pakistani Chinese Black African Mixed ethnic group (please state): Any other ethnic group (please state): Disability: Under the Disability Discrimination Act 1995 a person is considered to have a disability if s/he has a physical or mental impairment which has a substantial and long-term adverse effect on his/her ability to carry out normal day to day activities. Do you consider yourself to have a disability? If you answered yes please state the nature or effects of your disability.: Sexual Orientation: Please indicate your sexual orientation by ticking the appropriate box: Heterosexual Bi-Sexual Gay/Lesbian Marital Status / Civil Partnership Status Are you married or in a civil partnership? Dependants/ Caring Responsibilities: Do you have dependants or caring responsibilities for family members or other persons? National Insurance Number: If yes, please indicate who you look after A child/children A disabled person(s) An elderly person(s) Date completed: Please complete this questionnaire and return it by or in a separate sealed envelope for the attention of the Monitoring Officer.

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