Job applied for: Chief Executive
Job reference number: Ref No: 13/35
Closing Date: 12midday on Monday, 14 th October, 2013
Mr  Mrs  Miss  Ms  Dr  Other
Surname: First Names:
Home address and postcode:
Telephone number (daytime): (evening):
Email address:
KW SF11 APPFORM NO DBS Web created 08/04/2008 by HJT/CS/AM review Jan 09
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1

Do you have any restrictions on working in the UK?
Yes  No 
*If yes, do you hold appropriate work visa/permits for the full term of this job?
Yes

No

*It is unlawful to employ a person aged 16 or over who does not have permission to live and work in the UK. You will need to provide us with one of the following documents:
A) Your passport, Birth Certificate or National ID card (for European Economic Area members only).
OR
B) A document providing your permanent National Insurance Number (e.g. P45, P60) plus one of the following; Birth Certificate (issued in the UK, Ireland, Isle of Man or
Channel Islands) Certificate of Naturalisation as a British Citizen, letter from Home
Office, granting indefinite leave to remain in the UK, Residence Permit.
OR
C) Your work permit plus one of the following: A passport or other travel document that shows leave to enter and take up work in UK, letter from Home Office proving right to enter and take up work.
We will not be able to employ you if you cannot produce one of these documents when requested.
Job Title: Salary:
(if successful you will be required to produce
Your employer: evidence of your salary)
Address and postcode:
The date you started: The notice you have to give:
The reason for leaving: The date you left(if applicable):
Please give brief details of your duties and responsibilities:
KW SF11 APPFORM NO DBS Web created 08/04/2008 by HJT/CS/AM review Jan 09
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Dates (mm/yy) Your employer’s Your job title and Reason for leaving
From To name and address main duties
Continue on additional sheet if necessary
Are there any gaps in your employment history? Yes  No 
If yes, please explain these:
PTO
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Qualifications Awarding Body Date of Completion
Membership of Registered Body
Registration number: Expiry Date:
GMC 
NMC

(Part )
Other  please state ________________________________
Dates (mm/yy) School, college or Exams that you
From To University passed
Please give details of any voluntary and community work you have been involved in.
KW SF11 APPFORM NO DBS Web created 08/04/2008 by HJT/CS/AM review Jan 09
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4

Please explain why you are applying for this job. Based on the person specification, provide specific examples to show how you meet each one of the essential and desirable criteria (if you need more space you may continue on a separate sheet but no more than two sides of A4).
KW SF11 APPFORM NO DBS Web created 08/04/2008 by HJT/CS/AM review Jan 09
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5

We need to take references covering your last three years of employment. One referee must be your current employer. The nominated referees should be someone with line management responsibility who has supervised your work or a university or college tutor
(if in further education within the last 3 years). We will not accept personal references.
References will be taken up on shortlisting.
If you do not wish us to contact your present employer prior to interview, please
 in the space below.
Current Employer Previous Employer
Name: Name:
Position: Position:
Address and postcode: Address and postcode:
Telephone number: Telephone number:
PLEASE DO NOT TAKE UP THIS REFERENCE
AT THE PRESENT TIME:

PTO 
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Do you hold a current driving licence: YES/NO Enter Endorsements (if any), offence code and number of points issued?
Have you ever been convicted of a criminal offence YES/NO
Are you currently the subject of any investigation or proceedings by anybody having regulatory functions in relation to health / social care professionals including such a regulatory body in another country?
YES/NO
Please give details on a separate sheet.
Have you ever been disqualified from the practice of a profession or required to practice it subject to specified limitations following a fitness to practise investigation by a regulatory body, in the UK or another country?
YES/NO
Please give details on a separate sheet
DATA PROTECTION ACT 1998
Kirkwood Hospice will hold personal details of all applicants on computerised and manual records. Personal information will not be disclosed to a third party without your consent except where exemptions in the Data
Protection Act exist. Anonymised personal data may also be processed by Kirkwood Hospice for research and statistical purposes.
Forms of unsuccessful candidates will be destroyed after six months.
DECLARATION
I declare that the particulars given are correct and l have not withheld any facts that may unfavourably affect my application. I accept that to withhold or falsify information could result in the termination of my contract. I agree to a medical examination if necessary. You can treat this as part of my contract of employment if I get the position.
Signed: Date:
PLEASE NOW CHECK THAT ALL SECTIONS OF THIS FORM HAVE BEEN COMPLETED
SHORTLISTING
Yes/No
CRITERIA
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Equality & Diversity Data Collection Form
The Board of Trustees and Management Team of Kirkwood Hospice are committed to being open, honest and fair to all employees. We firmly believe that it is everyone’s right to be treated with dignity and fairness regardless of age, race, gender, religion or belief, sexual orientation, disability or marital status.
The data we collect will help us to monitor the diversity of our current workforce and to provide fair, open and honest treatment for our employees. The data will not be used for any other purpose.
Completing the questionnaire isn’t compulsory but by doing so you will be helping to make us a more accountable and transparent employer and to ensure we have sound information about the diversity of those who work for us to meet the requirements of the Equality Act now and in the future.
All data we have about employees is held securely and access is tightly controlled. In the case of your equality and diversity data, this will be held in a separate secure area of our database. Only those staff who are involved in maintaining the database and compiling statistics will have access to the data. The data will be used to generate statistical reports and undertake equality impact assessments.
Job Ref: 13/35
Surname:
First Name(s):
Date of Birth:
Where did you see the vacancy advertised:
Place an  in the boxes using black ink.
Are you: Male  Female  Prefer Not To Answer
Please choose one box below which most closely matches your ethnic background.

White
British
Irish
Any other



Black or Black British
Caribbean
African
Any other Black



Mixed Group
White & Black Caribbean 
White & Black African
White and Asian
Any other Mixed


 White background background
background
(Please specify below if you wish) (Please specify below if you wish) (Please specify below if you wish)
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian




background
Chinese
Chinese 
Any other Chinese 
Other background
Other 
background
(Please specify below if you wish) (Please specify below if you wish) (Please specify below if you wish)
Prefer Not To Answer 
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Disability
Are your day to day activities limited because of any health problem or disability which has lasted or is expected to last at least 12 months. Place an  in one box only.
Yes-limited  Yes-limited a little  No  Prefer not to answer 
Disability is legally defined as a ‘physical or mental impairment which has a substantial and long term adverse effect on a person’s ability to carry out normal day-to-day activities’. This can include “hidden” conditions such as mental health conditions, epilepsy or diabetes for example.
Sexual Orientation
Bisexual 
Gay Man 
Prefer not to answer 
Gay Woman/Lesbian
Other
 Heterosexual/Straight 

Which most closely matches your religion or beliefs?
Buddhist 
Jewish 
Prefer not to answer 
Christian
Muslim
Other



(Please specify below if you wish)
Hindu 
Sikh 
I have no religious beliefs 
Age Band:
Under 25
45 to 54
Marital Status:
Married
Separated




25 to 34 over 54
Single
Cohabiting




35 to 44
Prefer not to answer
Divorced
Prefer not to answer




If you have particular requirements in respect of any interview or selection test please give us details in the space below:
Name (in BLOCK CAPITALS):
The job that you have applied for:
Job Reference Number:
Details of particular requirements you might need:
If you have any questions or want to discuss your application in confidence, please contact
Human Resources Administrator on tel: 01484 557900. Email: annm@kirkwoodhospice.co.uk
To be completed electronically and converted to a pdf version prior to e-mailing to
Annm@kirkwoodhospice.co.uk
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KW SF11 APPFORM NO DBS Web created 08/04/2008 by HJT/CS/AM review Jan 09