East Lancashire Hospice | Covering Blackburn, Darwen, Accrington and Clitheroe areas

Telephone
01254 287000

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Application form

Post applied for:
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Where did you see this job advertised?

Personal information

Title:
First name:
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Last name:
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Address:
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City:
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Phone:
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Mobile:
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Work:
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Do you hold a current driving licence?
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Are you presently a vehicle owner?
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General education

Qualification:
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Level:
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Grade:
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Date gained:
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Professional qualification

Qualification:
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Level:
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Grade:
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Date gained:
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Post graduate qualifications

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Level:
Grade:
Date gained:

On going study relevant to this post

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Provider:
Date started:
Date expected to complete:

Details of other courses relevant to this post

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PIN number / professional registration

Professional body:
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Number:
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Expiry date:
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Have your ever been reported to your professional body?
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Do you require a permit to work in the UK?
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Please give permit number:
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Employment

Current employer / previous employer:
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City:
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County:
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Postcode:
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Post title:
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Grade:
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Date commenced:
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Date left:
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Salary:
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Reason for leaving:
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Period of notice required:
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Previous posts

Name of employer:
Post held:
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Date from:
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Date to:
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Reason for leaving:
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Supporting information

Please give a short description of your relevant knowledge, skills and experience to support your application for this post.

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References

Please give two referees (not relatives). If you are currently employed one must be your present employer or last employer if not currently in employment. If you are a school leaver referees must be from your school or college. Both referees will be contacted after you have received your conditional offer of employment.

Reference 1

Name:
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Relationship:
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Address:
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City:
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County:
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Postcode:
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Phone:
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Email:
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Reference 2

Name:
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Relationship:
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Address:
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City:
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County:
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Postcode:
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Phone:
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Email:
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Disclosure of criminal offences

If the role for which you are applying involves regular, direct, unsupervised contact with people receiving health care the post is exempt from the Rehabilitation of Offenders Act 1974. This means that if you are successful at interview the hospice will request an enhanced DBS check via our umbrella organisation “Personnel Checks” as part of the pre-employment screening process. You will then be asked to complete an online form by “Personnel Checks” to progress the DBS check. For more information on how the hospice will deal with information disclosed via DBS checks please refer toour Statement on Secure Storage, Handling, Use, Retention and Disposal of Disclosures and Disclosure Information which is available on our website.

Privacy notice: recruitment (Staff)

East Lancashire Hospice will process information provided on this form in order to progress your application through the recruitment process including: shortlisting, interview and new starter checks. This information will be stored in paper format and stored in a locked drawer within a locked room it will be accessible to the General Administration Team, the Head of Corporate Administration, and the recruiting manager. Should you be invited to interview, the interview panel members will also have access to this information for the duration of the interview process. We will also store electronic versions of this form along with correspondence and pre- employment check information (excluding DBS). This will be accessible to the General Administration Team, the Head of Corporate Administration, and the Development and Support Services Manager. DBS information is retained in paper copy for 12 months then shredded.

In addition your name, address, contact details and the role you are applying for will be inputted onto our HR database. This is accessible to the General Administration Team, the Head of Corporate Administration, and the Development and Support Services Manager. The paper and electronic versions of your information will be retained for 6 months prior to being destroyed by shredding or deletion should your application prove unsuccessful. A record of your application will be retained on the HR database for 6 months to enable analysis of how the hospice manages recruitment. Any reports will be anonymised. Should your application prove successful the information in hard copy will be added to your personnel file. Your details will remain in your personnel file and on the HR database for the duration of your employment and for 6 years after you leave the organisation. It will then be destroyed by shredding or deletion. Should you have any questions, concerns or objections regarding information we hold please contact the Development and Support Services Manager on 01254 287000. Please sign to consent to the processing and storing of this information as indicated above.

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Details of any reasonable adjustments required for the recruitment process:

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