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APPOINTMENTS UNIT - APPLICATION FORM
DH1/15/289218
Department of Health, Social Services and Public Safety
BELFAST HEALTH & SOCIAL CARE TRUST
APPOINTMENT OF NON-EXECUTIVE DIRECTOR WITH
FINANICAL EXPERIENCE
(BHSCT 2/15)
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Applications must be made using this form – CVs and additional pages will not be accepted.
Please write legibly and use black ink or typescript (minimum font size 12).
This application form can be made available in other formats on request. Please contact
028 9076 5606 for details.
Please complete all parts of this form and return your application to the address below. The
closing date for this appointment opportunity is 12.00 noon on Thursday 17th December 2015.
Forms received after the closing time and date will not be accepted.
DHSSPS Appointments Unit,
Room D1,
Castle Buildings,
Stormont Estate,
Belfast BT4 3SQ
For official use only
Application Form Received
Officials Name & Date
e-mail: public.appointments@dhsspsni.gov.uk
1.
PERSONAL DETAILS
Title:
Surname:
Forename(s):
Postal Address:
Postcode:
National Insurance Number:
Tel No:
Mobile No:
E-mail address:
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2.
SUITABILITY FOR APPOINTMENTSUITABILITY FOR APPOINTMENT
Complete each box below using the space provided, additional sheets will not be accepted
(if typing - minimum font size 12).
Drawing on either your working life or personal life, complete the boxes below:
(i) Business Sense –
Exercising judgement and critical thinking about issues that the Belfast HSC Trust Board considers
as a matter of course, for example issues of business planning, resource allocation, risk
management and organisational performance.
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(ii) Corporate Governance –
Working at or close to Board level within a framework of corporate governance, demonstrating
personal awareness of the importance of effective governance, including effective differentiation
between executive and Non-Executive roles and the role of Non-Executive Directors in holding
executive Directors to account.
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(iii) Stakeholder Engagement –
Promoting effective relationships within and without organisations, for example between investors or
funders and managers or in partnerships between different organisations.
.
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(iv) Self Awareness and Personal Contribution Maintaining a conscious sense of self and authority in a group in a way that mitigates ‘group-think’.
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(v) Financial Management Responsibility and Experience –
Applying financial management principles in an organisational setting with a financial turnover of
greater than £10m per annum.
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3.
CURRENT EMPLOYMENT
(current employment & voluntary work plays no part of the selection process, however this information is
used to identify any potential disqualifications and/or conflicts of interests only)
2.
PREVIOUS EMPLOYMENT AND/OR VOLUNTARY WORK EXPERIENCE
Are you currently employed?
YES
NO
(Please indicate by ticking against your answer)
If YES, please give details below.
Date: From
To
Organisation:
Position/Main Responsibilities:
4. VOLUNTARY WORK
Are you currently involved in voluntary work?
YES
NO
(Please indicate by ticking against your answer)
If YES, please give details below.
___________________________________________________________________________________
Date: From
To
Organisation:
Position/Main Responsibilities:
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5.
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CURRENT PUBLIC APPOINTMENTS
Do you currently hold any public appointments?
YES
NO
(Please indicate by ticking against your answer)
If NO please go to Section 9.
If YES please list all current public appointments giving the years you have held the appointment
3.
PREVIOUS AND CURRENT PUBLIC APPOINTMENTS
Dates: From
To
Organisation & Sponsoring Department:
Position/Responsibilities:
Remuneration Fees Paid:
Dates: From
To
Organisation & Sponsoring Department:
Position/Responsibilities:
Remuneration Fees Paid:
Dates: From
To
Organisation & Sponsoring Department:
Position/Responsibilities:
Remuneration Fees Paid:
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6.
INTEGRITY/PROBITY AND CONFLICTS OF INTEREST
Before you complete this section, it is important that you read the leaflet “CPANI, The Commissioner for
Public Appointments” and the additional guidance on “Probity and Conflicts of Interest” which is included
in your application pack.
Are there any real, perceived or potential conflicts of interest between your circumstances and the
appointment for which you have applied?
YES
NO
(Please indicate by ticking against your answer)
If you answered YES, please provide details below
Have you been involved in activities that could call into question your own reputation and/or damage the
reputation of this organisation?
YES
NO
(Please indicate by ticking against your answer)
If you answered YES, please provide details below
NOTE:
Conflicts of interest will be explored at interview.
ECLARATION
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7.
DECLARATION
I declare that the information I have given in support of my application is true and complete to the
best of my knowledge, is an accurate reflection of my own individual experience, personal
achievements and undertakings and all statements contained therein relate to me personally.
I have read the information pack and understand my responsibilities in relation to statutory
disqualifications and public appointments. I understand that, if I am appointed and the
information I have provided is incorrect, or any of the statements made in this declaration are
untrue, or subsequently circumstances arise at any time before the end of my term of office
which would render any such statements untrue, then my tenure of office may be terminated. In
addition, I undertake that, if appointed, I must raise with the Chief Executive of the public body
any probity or conflict of interest issues that might arise during my term of appointment and that
my failure to do so could lead to my appointment being terminated.
I understand and accept that the information I have provided in this form will be processed by the
Department of Health, Social Services & Public Safety, in accordance with its Data Protection
Registration, for the purposes of making public appointments. This may involve disclosing
information to other Government Departments, the Commissioner for Public Appointments for
Northern Ireland and anonymously in response to Parliamentary Questions and other enquiries. I
also understand and accept that, if appointed, my name will be published in the Public
Appointments Report. In addition, if appointed some of the information contained in my
application will be used for a Press Release.
I have read the leaflet entitled “CPANI, The Commissioner for Public Appointments Northern
Ireland” and the additional guidance on “Probity and Conflicts of Interest” and have completed
Section 6 accordingly.
Signature:
Date:
Please save file and submit to e-mail: public.appointments@dhsspsni.gov.uk
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