Application Form

THG staff recognise their responsibilities to develop and maintain an

awareness of correct practise to comply with the Healthcare Commission’s Core
Standards. Our Recruitment and Selection procedures for THG staff are designed to
make sure our Patient’s are treated in a safe, friendly environment by ensuring that
only suitable individuals are appointed.

CONFIDENTIAL
Post applied for: Closing date:

Location: Hours per week:

Agency used (if applicable) Where did you see the position advertised?

Details of Candidate (use BLOCK letters)

Surname: Griffin Title: (Mr, Mrs, Miss, Ms, Other)
Mrs
First Names:Nicola

Any previous surname(s):

Current Address: Telephone No. (inc. area code)

47 Holdenhurst Road Kingswood Bristol Home:01179 671526
Mobile:07890892515
Best for daytime:07890892515
Best for evening:07890892515
Postcode: Email:donk47@hotmail.com

Do you hold a current Driving Licence?yes

Do you have access to a vehicle?

yes
Under the Asylum & Immigration Act 1996, it is
unlawful for THG to employ anyone over 16
who does not have permission to live and work
in the UK. To ensure that the Hospital fulfils its
requirements under the Act, please provide the
following information:
NI Number:
Do you require a Work Permit? Work
Permit No. Exp date:
N/A
In order for us to comply with the provisions of the Disability &
Discrimination Act 1995, please advise us of any special requirements you may have when attending an
interview.

N/A

The purpose of this question is to comply with out duties under the Disability & Discrimination Act 1995.
Do you have any condition or other circumstances that will prevent you from carrying out the duties of the post?

N/A

Education

High School, colleges and Dates attended Qualifications gained

universities attended. (Most To & from (dates, levels, grades etc.)
recent first)
Bath college, Hanham High

Courses Attended

Type/name of training course Course duration Date of training

Professional Qualifications

Dates Professional body Qualifications Date obtained / awarded

to and from

Professional body:
Registration number:

Expiry date:

Details of current
membership of
professional
organisations (grade
and date achieved):
Employment History
Please provide details in sequence with the most recent first. Where you have
had a break in your employment, please give details.

Name, address and Position held and main Dates Reason for leaving and
nature of business duties to and from current salary

Have you ever been involved in any disciplinary proceedings or subject to a disciplinary
investigation?
No

In addition, please confirm whether there have been any allegations raised against you or any
other investigations previously?
N/A

If yes, please state the nature of the allegation/investigation/proceeding and outcome. (Continue
on separate sheet if necessary)

How much notice does your present employer require?

None

References

Please give details of two referees whom we

may approach for a reference. These must be
from your last two employer’s. As references
will usually be taken up prior to interview,
please indicate if you do not wish any of your
referees to be contacted at this stage.
1. Name of Company:Sainsburys 2. Name of Company:Adam Lee
Name of referee: Name of referee:April Milson
Address: Address:

Postcode: Postcode:
Telephone: Telephone:
Fax: Fax:
Email: Email:
Position held: Position held:
Third reference is only needed for clinical
positions.
3. Name of Company:
Name of referee:
Address:

Postcode:
Telephone:
Fax:
Email:
Position held:

Your Health

Please state the number of periods of sickness and absence you have had and also the amount of
days this has equalled up to within in the last twelve months.

Number of periods:

Number of days:

Comments:

Skills and Experience

In your own words, please explain why you consider yourself suited to this position
outlining what you would contribute to the post if appointed, by reference to the job description and/or person
specification.
(You may, if necessary, continue on separate sheets, using no more than 2 additional
pages)
Rehabilitation of Offenders Act 1974

The position for which you are applying is exempted from the Rehabilitation of Offenders Act 1974. this means
that you must declare all criminal convictions, including those that would otherwise be considered “spent”.
Answering “yes” to any of the questions below will not necessarily bar you from being appointed. This will
depend on the nature of the position for which you are applying and the particular circumstances.

Are you currently bound over or have you ever been convicted of any offence by a Court or Court-martial in the UK or in any other
country? (note: you do not need to mention parking offences)

If yes, please include details of the other binding you over and/or the nature of the offence, the penalty, sentence or oder of the Court,
and the date and place of the court hearing:

Have you ever received a police caution, reprimand or final warning?

If yes, please include details of the caution, reprimand or final warning, including the date and reason administered:

Have you been charged with any offence in the UK or in any other country that has not yet been dealt with? (please note: you must
inform us immediately if you are charged with any offence in the UK or in any other country after you complete this form and before
taking up any position offered to you. You do not need to tell us if you are charged with a parking offence):

If yes, please include details of the nature of the offence with which you are charged, date on which you were charged, and details of
any on-going proceedings by a prosecuting body:

Clinical (qualified) staff only

Have you ever been disqualified from the practise of a profession or required to practise subject to specified limitations following
fitness to practise proceedings by a regulatory or licensing body in the UK or any other country?

If yes, please include details of the reason given for the investigation and/or the proceedings undertaken, the date, details of any
limitation or restriction to which you are currently subject, and the name and address of the licensing or regulatory body concerned:

Clinical (qualified) staff only

Are you currently the subject of any investigation or fitness to practise proceedings by any licensing or regulatory body in the UK or
any other country?

If yes, please include details of the reason given for the investigation and/or the proceedings undertaken, the date, details of any
limitation or restriction to which you are currently subject, and the name and address of the licensing or regulatory body concerned:
Other information in Support of your Application

Interests: Please describe any leisure or other interests, including voluntary/community work which you feel
may be relevant to the post or THG.

Do you know of anyone currently working for THG?

Declaration

I declare that all of the information I have provided with this application is true to the best of my knowledge and
belief, and that I have not withheld any relevant information. I understand that if I have made any false
statements or omitted any information either on this form or on my pre-employment health questionnaire, I am
liable to have my application rejected, or if appointed, liable to disciplinary action which may result in dismissal
on the grounds of dishonesty.
I declare that there is no reason why I should not be considered to work in a Healthcare environment.

Personal Data supplied on this form will be held on/and or verified by reference to information already held on
computer for a period of up to six months. In signing this application form you give permission to THG to
access, store and process this data, some of which will include ‘sensitive data’.
Data Protection Act 1998

Please ensure that the application form is completed fully. CVs will be accepted, but assessment for
interview will be made from the application.
Have you ever been involved in any disciplinary proceedings or subject to a disciplinary investigation?
Yes No

In addition, please confirm whether there have been any allegations raised against you or any other
investigations previously.

If yes, please state the nature of the allegation/investigation/proceeding and outcome. (Continue on separate
sheet if necessary)