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Delivering Quality Healthcare

Application Form

ALL INFORMATION GIVEN ON THIS FORM WILL BE TREATED AS CONFIDENTIAL

Position Applied For: SUMMER PLACEMENT

Please be aware that at the end of this form you will be asked to declare that all the statements you make are true to the best of your knowledge and state that is the event of you being enrolled and it subsequently being shown that medical information was not disclosed by yourself, or was found to be misleading or false, your placement may be terminated.

Mr/Mrs/Miss/Other (specify) Surname:

Forename: Maiden Name:

Address:

Post Code: No of Years at Address:

Telephone: Mobile No:

Date of Birth: E-mail:

Next of Kin Name:

Next of Kin Address:

Next of Kin Telephone Number:

Candidates Nationality (please tick)White: Black

Caribbean:Indian:

Chinese: Pakistani: Other (please state):

Please indicate if you will require a work permit?

Yes No

Registered Disabled: Yes No

Registered Disabled Number:

Give details of operations, major illness and disabilities during the last 5 years.

www.jhootspharmacy.co.uk

HR V1 17/02

Delivering Quality Healthcare

Do you hold a current driving licence?

Yes No

Give details of any driving licence endorsements:

Give details of any legal proceeding taken against you that are not spent under the rehabilitation act.If you are related to anyone in the company please give details.What are your reasons for wanting to undertake a Summer vocational placement?

Which university are you studying at:

What year are you in:

Education: Please list Professional Training/ Qualifications with dates and levels attained (Please indicate any study in progress):

Please Tick as appropriate.

Yes NoIf you answer ‘No' to Question 1 or ‘Yes’ to any other question please provide further details in the box provided.

1 Are you currently in good health?2 Have you ever left, or been denied, a job on health grounds?3 Have you ever been denied a driving licence on health grounds?4 Do you consider yourself to be disabled?5 Are you Dyslexic or do you have specific learning difficulties?

6Have you any disabilities affecting standing, walking, lifting, driving, stair climbing or the use of your hands?

7Have you any disabilities affecting your hearing which cannot be corrected by the use of a hearing aid?

8Have you any disabilities affecting your sight which cannot be corrected by the use of a spectacles or contact lenses?

9Have you experienced any problems from using display screen equipment or computers?

10Have you experienced any problems in confined spaces or using lifts?

www.jhootspharmacy.co.uk

HR V1 17/02

Delivering Quality Healthcare

11Have you experienced any particular problems with your memory, mood and ability to concentrate, or understand?

12

Have you experienced any particular problems coping with stressful situations, such as working to demanding time lines or under other pressures?

13Have you ever been or are you being treated for abuse of an addictive substance including alcohol or illegal drugs?

14Have you seen a Specialist or been admitted to hospital within the last two years?

15 Are you attending an outpatient clinic?

16Are you waiting to see a Specialist or attend a hospital appointment?

17 Are you currently recovering from an operation, illness or accident?18 Are you taking any prescribed medicine?Please Provide further details in relation to any of the above statement. Indicate the statement number(s) referred to with your response below.

Statement

1. I declare that all the foregoing statements are true to the best of my knowledge. I accept that in the event of me being provided with work and it is subsequently shown that the information disclosed by me has been misleading or false, that the employer may terminate my placement.

2. I understand that I may in confidence be requested to complete a full medical questionnaire, which will be completed in confidence and reviewed by the Occupational Health Service.

3. I understand that the Company may refer me to the Occupational Health Service for possible consultation and physical examination.

4. I consent to this information being held by the Company and this information may be processed. Computerised, stored and linked to other personnel data held by the Company.

PRINT NAME:............................................. Date:............................

Internal Use only- Checked and authorised:

Signed:........................................................... on behalf of Jhoots Pharmacy.

www.jhootspharmacy.co.uk

HR V1 17/02

Delivering Quality Healthcare

www.jhootspharmacy.co.uk