Job Application Form

The Job Title:

Job Reference:

YOUR DETAILS

Name?

Home address?

Home number?

Mobile number?

Email address

16 years old or older? Please circle

Yes No

Are you allowed to work in the UK?

Please circle

Yes No

Do you need any support to do the job?

Please circle

Yes No

Do you have relatives that work for us?

Please circle

Yes No

Can you drive? Please circle

Yes No

This is about any paid or unpaid job you had

Current Work

Your work now?

16+

Is your work paid or unpaid?

What is your job title?

What tasks do you do?

When did you start your job?

When did it end?

Previous Work 1

Who did you work for before?

What tasks did you do?

Work

Work

When did you start this job?

When did it end?

Previous Work 2

Who did you work for before?

What tasks did you do?

When did you start this job?

When did it end?

Work

REFERENCES Please give details of 2 referees A referee is someone who knows you well but is not

family One of the referees should be your current or last

employer

Reference 1

Name

Job Title

Address

Phone number

Email address

How do they know you?

Reference 2

Name

Job Title

Address

Phone number

Email address

How do they know you?

SCHOOL AND COLLEGE

What school or college did you go to?

When did you leave school or college?

What training courses have you done.

When did you do that?

Name of course or exam

When did you do that?

Name of course or exam

When did you do that?

Name of course or exam

SUPPORTING STATEMENTWrite down why you think you would be good for this job

Hertfordshire Community NHS Trust is a disability confident employer. If you meet the core criteria for the post we will guarantee you an interview.

Is there anything we could do to help you?

For example, would you need help at an interview?

This section means we keep your personal information safe and may share it with other companies when we need to.

Data protectionIn accordance with the Data Protection Act 1998 the information provided in this application form may be sensitive personal data. Such data will be used to assess your suitability for the post and, if employed, this information will form the basis of your employee personnel file. The information provided on this form will be entered onto a computerised database. Additionally it may be necessary for the information you have supplied to be shared with other organisations and recommendations for other roles

By signing below, you give your consent to the Trust to record your sensitive personal data and to disclose the data given on this form to third parties in order to assess your application, any subsequent employment and for any matter relating to that employment.

If you are unsuccessful in your job application or withdraw, we shall hold your job application and other information supplied and any notes made by ourselves on our files for a period of 12 months after the closing date of the vacancy.

This section means what you tell us on this form must be the truth, or you may be dismissed.

Accuracy of InformationBy submitting your personal data you declare that all the information provided is true. Any such activity, or failure to disclose any personal relationship with a Director or employee of the Trust, will disqualify your application. If any of the enclosed information within your application is found to be untrue or misleading after your appointment, you may be liable for dismissal without notice. It is important that any information you provide is accurate and kept up to date. You can contact us regarding any queries or concerns by emailing us.

Signed…………….………………….. Date……….………

Please also fill in the equal opportunities form that comes with this application form. This helps us check that everyone is getting an equal chance to work for Hertfordshire Community NHS Trust.

Please sign the application form.