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Personal information Title Please select Mr Mrs Ms Miss Dr First name Last name Company Address Apt, suite, etc. City Country Afghanistan Albania Algeria Andorra Angola Anguilla Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Greece Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malaysia Mali Malta Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue North Korea Norway Oman Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Western Sahara Yemen Zambia Zimbabwe County/State Postcode/ZIP code Phone Mobile Email Do you hold a current driving licence? No Yes Are you presently a vehicle owner? No Yes General education Qualification Level Grade Date gained Professional qualification Qualification Level Grade Date gained 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 started Date expected to complete PIN number / professional registration Professional body Number Expiry date Have your ever been reported to your professional body? No Yes Do you require a permit to work in the UK? No Yes Employment Current / Last employer Address Apt, suite, etc. City County/State Postcode/ZIP code Post title Grade Date commenced Date left Salary Reason for leaving Period of notice required Previous posts Employer Post held Date started Date ended Reason for leaving Supporting information Please give a short description of your relevant knowledge, skills and experience to support your application for this post. 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 First name Last name Address Apt, suite, etc. City County/State Postcode/ZIP code Phone 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. Privacy notice East Lancashire Hospice is committed to protecting your information and privacy. We only collect your personal data when you give it us directly or from other health and social care providers involved in supporting you or your family. The information below provides an overview of how we comply with legislation and protect your information. PLEASE NOTE WE NEVER SELL YOUR INFORMATION ON TO THIRD PARTIES YOUR RIGHTS You have the right to be informed about how we collect and use your personal information This privacy notice sets out how we collect, use, protect, share, retain, archive and destroy personal information. You have the right to access information we hold about you You have the right to request that any incorrect or incomplete information we hold about you is corrected and completed You have the right to request that personal information we hold about you is erased You have the right to request we restrict processing of your personal information You have the right to request the personal information we hold on you be provided in a format that allows you to transport this information to others You have the right to access any profiles we carry out using your personal information You have the right to object to how we collect and use your personal information except where we are legally obliged to for example: If a serious crime has been committed If there is a risk to you or the general public To protect vulnerable children and adults Under a court order If you have any questions, concerns, want to exercise these rights or object to us processing your information please contact General Administration by: Telephone: 01254 287016 Email: general.administration@eastlancshospice.org.uk Post: General Administration, East Lancashire Hospice, Park Lee Road, Blackburn BB2 3NY. We process information on applicants to job vacancies and volunteer roles in order to ensure the effective management of their recruitment What information do we collect and use? We collect personal information listed below in order to manage recruitment Contact Details - Name, Postal Address, Email, Telephone numbers, Application details Interview records Pre-employment checks - references, occupational health questionnaires, DBS where applicable and identification documents Professional registration where applicable Immunity status where applicable Qualifications where applicable The lawful basis for us collecting this information is: As part of preparation to a potential contract of employment. In compliance with employment legislation. How we use your information We use your information to effectively manage your recruitment. Sharing your Information We share your information with your consent to our Occupation Health provider in order to effectively screen that you are fit for the post applied for. How we keep your information safe Training: All staff and volunteers are trained so they understand the law and their responsibility in regard to maintaining confidentiality, obtaining and using information appropriately, storing information securely and destroying information safely when it is no longer required. Access controls: Paper records are locked away securely and all electronic systems are password protected so that only those who are involved in processing applications have access to the information they need. Monitoring: We make regular checks to ensure that we meet the required standards and that your information is obtained, used, stored and destroyed in accordance with the law. Archiving and destruction: To comply with the law we keep your records for 6 months after you have applied unless you are successful in which case it is retained for 6 years after you leave the organisation. After this time, information is destroyed in line with best practice guidance, shredding paper documents and securely deleting electronic records. I confirm that I have read and understood the above, and give my consent to the hospice holding data relating to me strictly in accordance with the terms of the Data Protection Act 1998. Details of any reasonable adjustments required for the recruitment process: To the best of my knowledge the details in this application are true I understand that any misrepresentation found in this application after appointment may lead to dismissal. Please note only shortlisted candidates will be contacted Spam protection WCJFF58NP8Y4UR Type or copy & paste the code you see on the left side.
