Hillview Medical Centre
60 Bromsgrove Road
Redditch
B97 4RN
Tel: 01527 66511 Fax: 01527 599767
Application for Employment
Position applied for: Medical Receptionist
Personal Details
Title:
Mr/Mrs/Miss/Ms/Dr
Address:
Surname:
First names:
Former/Previous Surname:
Telephone Number:
Education
Dates
From - To
School/College/University
Exam Subjects
Taken
Grade
Obtained/Awaited
Date Obtained
Details of Courses Attended
Dates of Training Course Duration
Establishment Attended
Type of Training Course
Professional Qualifications
Professional Body – Training
School, etc
Dates
From - To
Qualifications
Date Obtained / Awaited
Professional Registration if applicable
Professional Body:
Registration Number:
Expiry Date:
Present or Most Recent Employment
Position Held:
Date of Appointment:
Name & address:
Salary/Wage:
Grade/Scale:
Notice Required:
Telephone number:
Date of Leaving(if applicable)
Previous Employment (most recent first)
Dates
From - To
Employer’s Name
Post Held
Grade/Scale
Reason for Leaving
Supporting Information
Please outline the duties of your present post and give details of any previous experience and achievements
which you feel are relevant to this application.
Please state briefly why you are interested in this position and what experience you feel you can bring to the
job:
Please state reasons for leaving present employment:
References
Please give below the details of 2 referees whom we may approach for a reference. At least one must be
your present or most recent employer, (school or college if a student). Please state the capacity in which
each referee is known to you. REFERENCES MAY BE TAKEN UP PRIOR TO INTERVIEW, PLEASE
INDICATE IF YOU DO NOT WISH ANY OF YOUR REFEREES TO BE CONTACTED AT THIS STAGE.
However, please note that it is the Surgery policy not to make any decision following the interview until
references for all candidates have been obtained.
1.
Name:
2.
Name:
Address:
Address:
Telephone:
Telephone:
Fax:
Fax:
Capacity Known:
Capacity Known:
At what stage can we approach your referee:
At what stage can we approach your referee:
Prior to Interview
YES/NO
Prior to Interview
YES/NO
After Interview
YES/NO
After Interview
YES/NO
Health
Please state the number of periods of sickness absence and total number of days sickness you have had in
the last 2 years.
Number of periods:
Number of days:
Your comments, as appropriate:
Are you registered disabled:
Rehabilitation of Offenders Act 1974
This post is exempt from the provisions of Section 4(2) of the above Act. Applicants must not withhold
information about convictions which for other purposes are “spent” under the provisions of the Act. In the
event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action.
Any information given will be completely confidential and will be considered only in relation to an application
or positions to which the Rehabilitation of Offenders Act 1974(Exemptions) Order 1975 applies.
Do you have any convictions (including spent convictions), to declare?
Yes/No
If yes please give details.
Declaration
I understand that any appointment, if offered, will be subject to the information given on this form
being correct. I also understand that an appointment will be subject to satisfactory medical
clearance and, as appropriate production of evidence of qualifications/registration.
Signature:
Date: