Application Form

Application Instructions

Thank you for considering job opportunities with Marillac Neurological Care Centre. Please complete all applicable sections on this form to the best of your ability. Please feel free to contact us should you have any questions.

1. APPLICATION FOR EMPLOYMENT

Job Role:

Please state your job role.

Where did you learn of this role?

Please state where you learned of the role.

2. PERSONAL DETAILS

Surname:

Please state your surname.

Title

Please state your title.

National Insurance No. (UK):

Please enter your national insurance number.

Email Address:

Please enter your email address.

Address:

Please enter your home address.

Forename/s:

Please state your forename.

Date of Birth (optional):

Please enter your date of birth.

Tel No (Home):

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Tel No (Mobile):

Please enter your mobile number.

Postcode:

Please enter your postcode.

Nationality:

Please enter your nationality.

If you are not a British passport holder, or you do not have the permanent right to remain in the , you will require a work permit.

Subject/Qualifications

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Place of Study

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Grade/Result

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Year/s

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5. TRAINING COURSES ATTENDED

Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking.

Subject/Qualifications

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Place of Study

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Grade/Result

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Year/s

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6. MEMBERSHIP OF PROFESSIONAL BODIES

If professional registration is not required for the role you are applying for then please move to section 7.

If you are registered to a Professional Body ie. NMC/HCPC then please enter the relevant details below.

Professional Body

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Membership or Registration Type

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Membership/Registration/PIN

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Expiry/Renewal Date

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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 investigation or proceedings by a licencing or regulatory body in the UK or in any other country?

Yes

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Have you been removed from the register or have conditions been made on your registration by a fitness to practise committee or the licensing or regulatory body in the UK or in any other country?

Yes

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7. CURRENT EMPLOYMENT

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

Employer Name:

Please enter your employers name.

Type of Business:

Please enter the type of business.

Start Date:

Please enter the day you started at the company.

Salary/Grade:

Please enter your salary.

Line Manager (Job Title and Name):

Please enter the name and job title of your previous line manager.

Please outline your duties and responsibilities:

Please outline your duties and responsibilities.

Job Title:

Please enter your past employers job title.

Address:

Please enter the address of the company.

End Date:

Please enter your last day at the company.

Notice Period:

Please enter the required notice period.

Company Telephone:

Please enter the company's phone number.

Reason for leaving (if applicable):

Please state your reason for leaving.

8. EMPLOYMENT HISTORY

Please outline in date order a complete history from the age of 18 onwards, providing full details for the last 8 years of employment.

Do not include your current/recent employer.

Please include your paid employment, education, volunteering activities and any other relevant activities/periods plus details of any breaks in your employment e.g., unemployment, travelling, studying, parenting etc.

Please ensure there are no unaccounted-for gaps between dates.

Where you have been employed by an agency outline the details of the agency rather than the placement.

Employment Dates

Employers Full Contact Details

Your Position Held

Start Date #1:

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End Date #1:

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Employers Details #1

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Position Held #1

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Start Date #2:

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End Date #2:

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Employers Details #2

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Position Held #2

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Start Date #3:

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End Date #3:

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Employers Details #3

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Position Held #3

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Start Date #4:

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End Date #4:

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Employers Details #4

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Position Held #4

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Start Date #5:

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End Date #5:

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Employers Details #5

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Position Held #5

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Start Date #6:

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End Date #6:

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Employers Details #6

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Position Held #6

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Start Date #7:

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Start Date #7:

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Employers Details #7

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Position Held #7

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Start Date #8:

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End Date #8:

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Employers Details #8

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Position Held #8

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9. INTERVIEW INFORMATION

If selected for interview, do you require any special arrangements to be made?

Yes

Please select yes or no.

If "yes", please give brief details:

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10. RELATIONSHIPS

If you are related to an employee of the Marillac Neurological Care Centre or have a relationship with an employee of the Marillac Neurological Care Centre, please state their name and your relationship:

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11. SUPPORT STATEMENT

In the space provided, please indicate:

Why have you applied for this role?
What skills, knowledge and experience can you bring?
How do you meet the role applied for?
Anything further that will aid your application.

You should ensure to refer to the provided Job Description throughout completing this section.

Please fill in the appropriate information.

12. REFERENCES

When providing references details please note the following:

You must provide two satisfactory references.
Please provide the names of individuals who have agreed to supply references.
If you are/have been employed your references should be your two most recent employers from two separate organisations. Employment references may include your line manager or supervisor/general HR department or senior colleague who can comment on your work experience, competence and personal qualities and suitability for the post.
Students can provide details of a teacher/lecturer at school, college or university.
Character references preferably should be a previous colleague or peer.

Please note personal references such as friends and/or relatives will not be accepted. We cannot accept references details of an employee currently working at the Marillac Neurological Care Centre due to our reference policy.

Referees will only be approached after an offer has been made. Please ensure you gain the consent of any referee prior to adding their information to the form.

Referee 1

Title:

Please enter the referee's title.

Full Name:

Please enter the referee's full name.

Job Title:

Please enter the referee's job title.

Organisation:

Please enter the referee's organisation.

Address:

Please enter the referee's address.

Email Address:

Please enter the referee's email address.

Tel. No:

Please enter the referee's phone number.

Referee 2

Title:

Please enter the referee's title.

Full Name:

Please enter the referee's full name.

Job Title:

Please enter the referee's job title.

Organisation:

Please enter the referee's organisation.

Address:

Please enter the referee's address.

Email Address:

Please enter the referee's email address.

Tel. No:

Please enter the referee's phone number.

13. DECLARATION

I declare that the information given in this application is true and complete. I understand that if I have given any misleading information on this form or made any omissions, this will be sufficient grounds for terminating my employment.

Signature:

Sign Above

Please enter your signature.

Date:

Please enter todays date:

Name (Printed):

Please enter your name:

The information provided by you on this form as an application will be stored on either paper records or a computer system in accordance witht the Data Protection Act (2018) and will be processed solely in connection with recruitment.

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