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

Telephone
01254 287000

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Application form

Post applied for:
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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County:
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Postcode:
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Contact details

Phone:
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Mobile:
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Work:
Email:
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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:
*
Grade:
*
Date gained:
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Professional qualification

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

Qualification:
Level:
Grade:
Date gained:

On going study relevant to this post

Course:
Provider:
Date started:
Date expected to complete:

Details of other courses relevant to this post

Course:
Provider:
Date attended:

PIN number / professional registration

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

Employment

Current employer / previous employer:
Address:
Post title:
Grade:
Date commenced:
Date left:
Salary:
Reason for leaving:
Period of notice required:

Previous posts

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

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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Telephone:
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Email:
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Reference 2

Name:
*
Relationship:
*
Address:
*
Telephone:
*
Email:
*

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 to our Statement on Secure Storage, Handling, Use, Retention and Disposal of Disclosures and Disclosure Information which is available on our website.

Data protection act

The hospice holds records relating to staff in accordance with the terms of the Data Protection Act 1998. The Act provides a system of registration for, and supervision of, data users and sets down principles in relation to the collation and storage of personal information. The principles are intended to protect the individual by placing restrictions and safeguards upon the type of information held. The Act confers on the individual the right of access to personal data, in prescribing circumstances and through a prescribed procedure. The exemptions to right of access to personal data are outlined in the Act. The Act restricts employee records detailing race, sexuality and trade union membership.

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Details of any reasonable adjustments required for the recruitment process:

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