www.pah.nhs.

uk

NHS STANDARD APPLICATION For Office Use Only

FORM Online Reference
Please fill in the Application form, which is split into Number:
three parts. Please complete the form and check it
carefully before returning it. If you wish to apply on-
line you can do so at www.pah.nhs.uk/jobs. Please PLEASE COMPLETE
APPLICATION FORM IN BLACK
note that questions marked with an asterisk * are INK (Failure to do this may result
mandatory and therefore must be answered. in your application being rejected)

APPLICATION FOR EMPLOYMENT WITH

The Princess Alexandra Hospital NHS Trust

APPLICATION FOR EMPLOYMENT
Details entered in this part of the form will be held in the HR department of the
recruiting organisation. Access to this information will be withheld from the
shortlisting panel.
Job Reference
Kate Cowhig International Healthcare Recruitment
Number
Job Title
Department
Personal Details

*Surname/Family Name

*First Names

Name in which you are

registered with a professional
body (if applicable)
Title
UK National Insurance No

Address

*Postcode/ Zip code

* Country
Home Telephone
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 www.pah.nhs.uk

Mobile Telephone

Work Telephone

May we contact you at work?  Yes  No

Email Address
*Are you a United Kingdom (UK), European Community (EC) or European
Economic Area (EEA) National?
 Yes  No
Please select the category that relates to your current immigration status. This
status will be subject to checking before interview.

 HSMP/Tier 1  Work Permit/Tier 2

 Indefinite Leave to remain/enter  Tier 5 Temporary Workers
 Post Graduate Doctors and Dentists  Refugee
 Dependant / Spouse visa  Other, please specify below
 Clinical attachment visa
 Student
 Visitor
 Working Holiday Visa/Tier 5 Youth Mobility

Please supply details of any visa currently held, including number, start/expiry
dates and details of any restrictions.

Visa No:
Start Date: (DD/MM/YY)
Expiry Date: (DD/MM/YY)
Details of Restriction:

Does your visa have a condition restricting employment or occupation in the UK?
 Yes  No

Are you a Department of Work & Pensions New Deal

 Yes  No
Candidate?
Are you an NHS professional returning to practice?  Yes  No
Do you currently work in the NHS?  Yes  No
If you have a disability, do you require any reasonable adjustments to be made
during the recruitment process, including interview?

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 www.pah.nhs.uk

 Yes  No

If yes, please supply details below;

If you have a disability, do you wish to be considered under the Guaranteed

Interview Scheme if you meet the minimum criteria as specified in the Person
Specification?

 Yes  No

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MONITORING INFORMATION
This section of the application form will be detached from your application form
and will be used for monitoring purposes only.

NHS Organisations recognise and actively promote the benefits of a diverse

workforce and are committed to treating all employees with dignity and respect
regardless of race, gender, disability, age, sexual orientation, religion or belief.
We therefore welcome applications from all sections of the community.

* Date of Birth
 Male
* Gender  Female
 I do not wish to disclose this
Race relations (Amendment) Act 2000
* I would describe my ethnic origin as:

Asian or Asian British Mixed Other Ethnic Group

 Bangladeshi  White & Asian  Chinese
 Indian  White & Black  Any other ethnic group
 Pakistani African  I do not wish to disclose
 Any other Asian  White & Black this
Background Caribbean
 Any other mixed
Black or Black British background
 African White
 Caribbean  British
 Any other Black  Irish
background  Any other White
background

Employment Equality Regulations 2003

* Please select the option which best describes your sexuality
 Lesbian
 Heterosexual
 Gay
 I do not wish to disclose this
 Bisexual
* Please indicate your religion or belief
 Atheism  Jainism  Hinduism
 Buddhism  Sikhism  Other
 Christianity  Judaism  I do not wish to disclose
 Islam this

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Disability Discrimination Act 1995 and 2005
The Disability Discrimination Act protects disabled people. The Disability
Discrimination Act defines disability as a physical or mental impairment with long-
term, substantial effects on the ability to carry out normal day to day activities.
This includes people with long-term health conditions. If you tell us that you have
a disability we can make reasonable adjustments to where you work and your
work arrangements and at interview.

 Yes
* Do you consider yourself
 No
to have a disability?
 I do not wish to disclose this information
Please state the type of impairment which applies to you. People may experience
more than one type of impairment, in which case you may indicate more than one.
If none of the categories apply, please mark ‘other’.
 Physical Impairment  Mental Health Problem
 Learning Disability/Difficulty  Long-standing illness
 Sensory Impairment  Other

Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into
work by allowing them not to declare criminal convictions to employers after the
rehabilitation period set by the Court has elapsed and the convictions become
‘spent’.
During the rehabilitation period, convictions are referred to as ‘unspent’
convictions and must be declared to employers.

Before you can be considered for appointment with the NHS we need to be
satisfied about your character and suitability.

The NHS aims to promote equality of opportunity and is committed to treating all
applicants for positions fairly and on merit regardless of race, gender, marital
status, religion, disability, sexual orientation, age or belief. The NHS undertakes
not to discriminate unfairly against applicants on the basis of a criminal conviction
or other information declared.

Anyone applying for a position which involves a regulated activity will require an
enhanced Criminal Records Bureau check and that the disclosure will, where
appropriate to the role, include information against the Independent Safeguarding
Authority barred lists for working with children or working with adults or both.

If you are applying for a post involving access to persons in receipt of health
services, your offer of employment may be subject to a satisfactory disclosure
from the Criminal Records Bureau. Failure to reveal information relating to any
convictions could lead to withdrawal of an offer of employment.

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Relationships
If you are related to a director, or have a relationship with a director or employee
of an appointing organisation, please state the relationship

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* DECLARATION

The information in this form is true and complete. I agree that any deliberate
omission, falsification or misrepresentation in the application form will be grounds
for rejecting this application or subsequent dismissal if employed by the
organisation. Where applicable, I consent that the organisation can seek
clarification regarding professional registration details.

I agree to the above declaration

Signature

Name Date

Where did you see this vacancy advertised?

 NHS Website  Local Newspaper  Doctor  Nursing Standard
 Search Engine  British Medical  Therapy  Other
 Other Website Journal Weekly Professional Journal
 National  Health Service  Nursing Times  Jobcentre Plus
Newspaper Journal  GP  Radio
 Hospital Doctor  Other

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APPLICATION FOR EMPLOYMENT

Details entered in this part of the form will be held in the HR department of the
recruiting organisation and will be made available to the short-listing panel.

Online
Job Reference
reference
Number
number
Job Title
Department

Education & Professional Qualifications

Include in this section all the relevant qualifications. Please also indicate subjects
currently being studied. All qualifications disclosed will be subject to a
satisfactory check.
Subject/Qualification Place of Study Grade/result Year

Training Courses Attended

Include in this section any relevant training courses that you have attended or
details of courses that you are currently undertaking.
Date
Course Title Training Provider Duration
Completed

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Membership of Professional Bodies
Include in this section any relevant professional registrations or memberships. If
you are registered then please enter the relevant details below; this information
will be subject to a satisfactory check.

* Please indicate your Professional Registration status if relevant to this post:

 I do not have the relevant UK
professional registration status
 UK professional registration
 I have current UK professional
required but not yet applied for
registration
 I am a student
 UK professional registration required
 Not required for this post
and applied for

If professional registration is not required then go to Employment History.

If you are registered then please enter the relevant details below:
Membership or
Membership/Registration Expiry/Renewal
Professional Body Registration
PIN Date
type

If you are applying for a post that requires professional registration you are
required to provide the following information:

Are you currently the subject of a fitness to practise

 Yes
investigation or proceedings by a licensing or regulatory body
 No
in the UK or in any other country?
Have you been removed from the register or have conditions
been made on your registration by a fitness to practise  Yes
committee or the licensing or regulatory body in the UK or in  No
any other country?

If applicable, please provide details of any conditions/restrictions you may have.

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Employment History
Please record below the details of your current or most recent employer

Employer Name

Address

Type of Business Telephone

Job Title
Start Date End Date
Start of continuous NHS service
Grade Salary
Reporting to (job Notice
title) Period
Reason for leaving (if applicable)

Description of your duties and responsibilities

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Previous Employment
Please record below the details of your previous employment, (minimum 3 years)
beginning with the most recent first. Up to 5 previous employments can be
entered here. If required, please provide additional information regarding your
employment history within the ‘Supporting Information’ section.

Previous Employer 1
Employer
Name
Address

Job Title Grade

From Date To Date
Reason for Leaving

Description of your duties and responsibilities

Previous Employer 2

Employer
Name

Address

Job Title Grade

From Date To Date
Reason for Leaving

Description of your duties and responsibilities

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 Previous Employer 3
Employer
Name
Address

Job Title Grade

From Date To Date
Reason for Leaving

Description of your duties and responsibilities

Previous Employer 4

Employer
Name

Address

Job Title Grade

From Date To Date
Reason for Leaving

Description of your duties and responsibilities

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Previous Employer 5
Employer
Name
Address

Job Title Grade

From Date To Date
Reason for Leaving

Description of your duties and responsibilities

Please add additional employers/information on a separate sheet.

If you have any gaps within your employment history, please state below.

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Supporting Information
In this section please give your reasons for applying for this post and additional
information which shows how you match the person specification for the job (you
will have been sent this document with the application form). This can include
relevant skills, knowledge, experience, voluntary activities and training etc. If
relevant to the post for which you are applying you should include details about
research experience, publications or poster presentation, clinical care (knowledge
and skills) and clinical audit.

Supporting information (Please continue on additional sheets if necessary).

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Additional Personal Information

Preferred  Full Time  Part Time  Job Share

Employment Type Secondment  Flexible Hours
If applicable to the post, do you hold a
certificate to support your responsibilities  Yes  No
under IR(ME)R 2000?

Evidence of relevant training and experience is required for those justifying or

undertaking x-rays, interventional radiology, CT scans etc. Please place this
evidence within your supporting statement.

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References
Please state the names and contact details of the people who have agreed to
supply references covering a minimum of 3 years employment/training. If you are
or have been employed, these should include your two most recent employers,
your line manager or someone in a position of responsibility who can comment on
your work experience, competence, personal qualities and suitability for the post.
If you are a student please provide contact details of a teacher at your school,
college or university. If you have not been in employment for a considerable
amount of time but have had previous employment, then you should seek one
reference from your last known employer and a personal reference from a person
of some standing within your community i.e. doctor, solicitor, MP etc. Where it is
not possible to obtain any employer reference at all then please obtain two
personal references. Where no personal reference can be obtained then
references should be sought from personal acquaintances not related to or
involved in any financial arrangement with you. If you have undergone training to
return to work then the academic institution should be contacted. Personal
references such as friends and relatives are not acceptable unless stated
previously.

Please note, all reference requests will be sought and employment history verified
through the organisation’s central Human Resources/Personnel Department or
equivalent therefore, please ensure that you provide their full contact details.
Referees may be contacted prior to interview.

Referee 1
*Surname/Family
First Name
name
Title
Job Title

*Address
*Post Code/ Zip
*Country
Code
Telephone Fax
Email
*Can the referee
be contacted
* Relationship  Yes  No
prior to
interview?

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Referee 2

*Surname/Family First Name

name
Title
Job Title

*Address
*Post Code/ Zip
*Country
Code
Telephone Fax
Email
* Can the
referee be
* Relationship  Yes  No
contacted prior
to interview?

If you have applied to us within the last 3

months, are you happy for us to use the  Yes  No
references from your earlier application?

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