Last Five Periods of Employment Prior to Above (most recent first)

Please note that prior to making an offer of employment, we are required by law to verify documentary evidence (and maintain copies for our files) regarding a candidate’s eligibility to work in the UK. This applies to all candidates regardless of nationality/origin.

Under the Rehabilitation of Offenders Act 1974 (Exceptions), (Amendment) Order 1986, it is compulsory to declare  every previous conviction whether spent or not when applying for any employment that has access to or substantial  contact with children, elderly people, the sick, and people with physical or mental disabilities.

Drawing on your experience/skills/abilities/qualifications (if applicable), please demonstrate why you feel you would be suitable for this post.

IMPORTANT NOTICE: The following will result in disqualification or dismissal if appointed for the post for which you are applying:

• Failure to disclose convictions, including ‘spent’ ones if applicable
• The provision of false information, either expressly or implicitly
• Wilful omission or suspension of any material fact

DATA PROTECTION ACT 1998: Information provided by yourself on this application form will only be processed in connection with your application for employment and for no other purpose. The information will be held securely and will only be accessible to authorised Practice employees. All information relating to unsuccessful candidates will be safely disposed of after the vacancy has closed. If successful in your application, this form will be held on your personal file.

Equal Opportunities Statement

The Practice is committed to eliminating discrimination from employment practices.

The Practice will take steps to ensure that employees are recruited, developed and promoted on the basis of ability, the requirements of the job and the need to maintain an efficient and effective service.

This form has been designed in conjunction with our Equal Opportunities Policy and the Disability Discrimination Act 1995. It is necessary for monitoring the effectiveness of the policy and our recruitment procedures and for consideration to be given to any specific support you may require because of adisability.

If you consider that your application has not been treated fairly, you should write to the Practice Manager with details of your complaint within 3 months of receiving the result of your application.

You will be asked to complete a Equal Opportunites Form after submitting your application. This information will be kept separately and will not form part of the selection process.

Please give names, addresses and telephone numbers of two professional referees (one must be your present or, if not currently working, your most recent employer). References from relatives are not acceptable

Referees, for shortlisted candidates, will be approached before interview unless you indicate otherwise by ticking the box provided. The Practice also reserves the right to contact any previous employer

Referee 1: Current or Most Recent Employer

Referee 2: Employer, prior to current or most recent employer