Application for Employment
Please use BLACK ink when completing this form. If you have any difficulty in completing this form please call the
Personnel Department on 020 8768 4500
Completed application forms should be returned to:
The Personnel Department, St Christopher’s Hospice, 51-59 Lawrie Park Road, Sydenham, SE26 6DZ.
Personal Details
Surname:
Forename(s):
Title: Dr. / Mr / Mrs / Miss / Ms / Other
Home Telephone No:
Address:
Work Telephone No:
Mobile Telephone No:
Postcode:
Email:
Post Details
Position applied for: _______________________________
How did you hear of the vacancy (If advertised please state the name of the publication): ______________________________
Are you looking for Full-time / Part-time / Temporary / Bank work? Please specify ____________________________________
Education & Training
Secondary Education:
Name of School/College
Dates
From / To
Exams Taken
Grade
Date
obtained
Further / Higher Education:
College/University
Dates
From / To
Exams Taken
Grade
Date
obtained
Please continue on a separate sheet if necessary
Professional Memberships & Registration
Name of Professional Body
PIN Number/Membership Number
Expiry date (if applicable)
Most Recent Employer
Name & address of Employer:
Job Title:
Dates Employed:
From:
Current or final salary:
To:
Period of notice required:
Reason for leaving (or seeking other employment):
Please give a brief outline of your main responsibilities:
Previous Employers
Name & address of
Employer
From
To
Post Held, Grade & Main Duties
Reason For Leaving
Supporting Statement
Please outline below:

Why you are applying for this job

How you satisfy the requirements of the job
You may find it helpful to look again at the job description and person specification and review the experience, skills and
knowledge we require. If you believe you have the necessary skills and experience please tell us about them.
Please continue on a separate sheet if necessary, writing your name and job applied for at the top.
Rehabilitation of Offenders Act 1974
Posts at the Hospice are exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act by virtue of the
Rehabilitation of Offenders Act (Exceptions) Order 1975. Applicants are therefore not entitled to withhold information about
convictions which for other purposes are ‘spent’ under the provisions of the Act. Any such information given will be completely
confidential and will only be considered in relation to your application for the post. Having a conviction will not necessarily
disqualify your application for the post.
Have you had any convictions
Please provide details of any convictions on a separate sheet.
Yes
No
Are you legally eligible to work in the UK?
Yes
No
Do you require a work permit?
If yes please give details
Yes
No
Have you ever been dismissed from previous employment?
If yes please give details
Yes
No
Do you hold a valid British Driving Licence?
Yes
No
Additional Personal Details
References
We require references from your two most recent employers, please provide contact details of the individuals we may write to.
Please note that if you have applied for a clinical position and are selected for an interview we will contact your referees prior to
the interview unless you notify us otherwise.
Name
Name
Job Title
Job Title
Name of organisation
Name of organisation
Address
Address
Contact tel
Contact tel
Contact fax
Contact fax
Contact email
Contact email
How long have you known this person and in what
capacity?
How long have you known this person and in what
capacity?
Declaration
I declare that the information contained in this application is complete and correct. I understand that if I have knowingly
provided false information, given misleading statements or withheld relevant details this could lead to the withdrawal of an offer
or subsequent disciplinary action, which could lead to dismissal.
Data Protection Act, 1998 - I understand that information contained on this form will be used for recruitment processing
purposes. Should my application be successful the details will also form the basis of my personnel record.
Signed
Thank you for taking the time to give us the information requested.
Date