Title: EASTERN HEALTH & SOCIAL SERVICES BOARD
Subject: App Form - 29/9/97
Author: -
Last saved by: emis2000
Company: BSO GMS

APPLICANT NO. | Rec/2026/

THE SURGERY
1 CHURCH STREET
NEWTOWNARDS
BT23 4FH

FOR ADMINISTRATIVE PURPOSES PLEASE STATE ANY DATES UNAVAILABLE FOR INTERVIEW

FROM                                   TO
The Surgery would like to point out that it is under no obligation to take account of your holiday arrangements but will endeavour to do so, where possible.

Please return to:
Recruitment Officer either by post or email:
Patricia Andrews 
Email:Patricia.Andrews@gp.hscni.net

By: Thursday 17^th September @ 4.00pm

PLEASE RETURN COMPLETED FORMS TO THE SURGERY BY 4.00 PM ON CLOSING DATE

APPLICANTS PLEASE NOTE
•	Please complete in BLOCK CAPITALS and in BLACK INK or TYPESCRIPT. 
•	Each section of this form must be fully completed.  If the section has insufficient space, applicants should continue on the continuation sheet attached to the application form.
•	Applicants should particularly note the contents of the Personnel Specification and indicate in their form how they meet the criteria.  Only information contained in the application form will be considered at shortlisting.
•	CVs will not be considered.

Surname:

Mr/Mrs/Miss/Ms/Dr
Other (please specify)

Forename(s):

Maiden Name
(if appropriate):

Other Name(s):

Home Address:

Postcode:

Address for Correspondence (if different):

Postcode:

Home Telephone No.
(incl STD Code)  

E mail:

Daytime Telephone No.
(incl STD Code)

Mobile No:

| National Insurance No. | | | | |

Do you hold a current full UK driving License?
Yes/No

Do you have access to a form of personal transport? Yes/No

Nationality:  EC/Non-EC | If Non-EC, please specify

EDUCATION - GENERAL

GCSE/‘O’ Levels/’A’ Levels/Other
Subjects passed | Examining Body | Level Attained | Grade Attained

FURTHER EDUCATION
Degree/Diploma/Certificate/NVQ | Awarding Body | Where obtained | Result obtained

EXAMINATIONS PENDING
Qualification(s) | Date to be taken

Please note that applicants will be required to produce evidence of those qualifications deemed as essential requirements of the post as detailed in the Personnel Specification prior to being appointed.

EMPLOYMENT HISTORY – PRESENT POST
Name and Address of present employer: | Title and grade of post:

Present Salary/Wage:
(please indicate whether weekly/ monthly/ per annum)
£

Status:
Permanent/Temporary

Period of notice required:

Department (if applicable): | Date appointed: | Day | Month | Year
Present duties and Responsibilities:

PREVIOUS POSTS (Beginning with most recent)

NB.  To assist consideration of your application you are advised to give precise dates for each period of employment, where possible.  This is particularly important when there are time considerations for shortlisting criteria based on experience/post qualification experience.

Employer

Grade/
Position

Please provide an outline of key duties, state level of wage/salary and reason for leaving

Dates

| | | From D/M/Yr | To D/M/Yr
| | . | |

Please account for any period since leaving school/third level education not covered by employment as stated previously
Please detail any other activities which may be relevant to your application (training/development courses attended etc)
Please state how your experience to date has a bearing on this application by providing information on how you believe you meet the criteria contained in the person specification:

Under the Rehabilitation of Offenders (Exceptions) Order Northern Ireland 1979, the Northern Ireland Health and Social Services are included in the list of excepted employments.  As such, any criminal conviction may never be regarded as spent and must be disclosed when applying for a post within the Health Service.

IT IS NECESSARY THEREFORE TO ASK THE QUESTION
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENCE 	YES	☐ NO	☐
IF YES PLEASE GIVE DETAILS
IT SHOULD BE NOTED HOWEVER THAT DISCLOSURE OF A CONVICTION DOES NOT NECESSARILY DEBAR ANY APPLICANT FROM OBTAINING EMPLOYMENT

MEDICAL HISTORY
Please give brief details and approximate dates of any periods of sickness during the past 2 years.
REASON FOR SICKNESS | LENGTH OF ABSENCE
Please make any comment in relation to your periods of illness stated if you wish.

REFEREES
Please name two referees, (not relatives) both of whom should have knowledge of your present/ most recent work and be in a supervisory/managerial capacity. 
Name: | Name:
Occupation: | Occupation:

Address:

Postcode:

Address:

Postcode:

Daytime Telephone No. | Daytime Telephone No.
Mobile No. | Mobile No.
E mail address | E mail address

DISABILITY DISCRIMINATION ACT

Please note in line with the act completion of this form is optional.
In accordance with the Disability Discrimination Act 1995, it is necessary for employers to consider making reasonable adjustments to accommodate a person with a disability.  Selection will continue to be made on the basis of the merit principle, however, in some instances it may be necessary to consider a person's disability and its impact upon the individual's ability to compete on equal terms with a non-disabled person.
In line with the Disability Discrimination Act 1995, a disability is defined as:

	"a physical or mental impairment which has a substantial and long term 
	adverse effect on your ability to carry out normal day to day activities".

Do you consider yourself to have a disability which may have an impact on the post you have applied for?
Yes                                               ☐                                         No                                     ☐
(Please provide appropriate details)

If you answered "yes" to this question, is there any reasonable adjustment which you believe is necessary for the Surgery to make to allow you to fulfil the requirements of the job for which you are applying, in full:

Do you require any special arrangements to be made for your interview?  If yes, please advise below:

Whilst the information given in this application is confidential, applicants are advised that legal processes may require the organisation to disclose the form to certain statutory bodies and, in some circumstances open Tribunal.

I hereby confirm that the information included in this application form is a true and accurate account.  (A candidate found to have knowingly given false information or to have wilfully suppressed any material fact will be disqualified or, if appointed, may be dismissed).

I understand that the appointment is subject to receipt of two satisfactory references as determined by the interview panel.
I consent to the information I have provided in this form being used for: 
  1.  processing my application for this post, including both manual and computerised 
       records;
  2.  transfer to the employment record if I am appointed, including both computerised and 
       manual systems;
  3.  inclusion in the Surgery’s annual monitoring return to the Equality Commission and 3 
       yearly reviews in summary format as necessary.

I consent to the information being retained for a period of a minimum of 12 months, or longer in the event of any legal proceedings taken against the Surgery by any applicant in connection with this appointment.

Signature: ____________________________	Date:_____________________________