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Job Application Form - Part 1

Please complete all sections of the form.

The outside pages of this application form (which contain all your personal details and the equal opportunities information) will be detached and retained in Tarporley War Memorial Hospital Confidential Personnel. This ensures that your application is dealt with objectively. Please complete ALL sections of this application form, regardless of whether or not you are submitting a CV for additional information, however you should not include any equal opportunities information on your CV.

General Data Protection Regulation
Information from this form will be processed in accordance with the General Data Protection Regulation. In signing it you agree to this data being held and processed and if appointed to the job you also agree to further personnel information, including sensitive data (e.g. bank details, medicals, etc) being held and processed by Tarporley War Memorial Hospital in accordance with the Act.

Title of job applied for
Personal Details
First Names
Known As
Previous Surnames
Post Code
Contact Details
Home Telephone
Work Telephone

We are committed to equality of opportunity for every one. To assess whether our Diversity Policy is effective, we need to monitor it and to do this we need the information requested below. We can then compare the success rates of different groups at both the short listing and appointment stages to ensure that unfair discrimination is not taking place. This will also enable us to comply with our obligations under current legislation.

The information below will be used only for monitoring purposes and not in the selection process. Please select from the options.

Marital Status
Date of Birth

How would you describe your ethnic origin?

Asian or Asian British
Black or Black British
Chinese or other
Any other background (please state)

Disability: The Disability Discrimination Act of 1995 made it unlawful for employers to discriminate against their employees who are disabled and places a duty on the employer to make reasonable adjustments to enable the employee to undertake the work. The definition in the Act is “People with disabilities are individuals who have, or have had a physical or mental impairment which has a substantial and long term effect on his or her ability to carry out normal day to day activities”. If you do consider yourself to be disabled under the definition in the Act, please indicate this, even if you do not currently need any adjustments to undertake your job.

Do you consider yourself to have a disability?

If you are shortlisted please let us know of any specific modifications that you may require.


Please provide two referees. One of these must be your present or most recent employer, or, for students, your personal tutor or head teacher. The second should, preferably, be a previous employer or someone who can comment on your suitability for this job.

Please let your referees know that you have quoted them as a referee, to expect a request for a reference and clarify how best to contact them, e.g. either letter, e-mail, should you be shortlisted.

If the referee knows you by a different name please state:

Different name
Present/most recent employer
Role in Organisation
Phone Number
Previous employer/other
Role in Organisation
Phone Number

*If you have not had previous employment, please provide details of another referee.

Reference requests will only be made if you are selected for interview. Please tick the box if you do not want us to contact your referees without your prior agreement.

Over the past two years, how many days have you missed work through illness?
You may wish to give a brief explanation
Please specify any reasons for gaps in your employment.
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Recruitment Monitoring
Please indicate where you first saw the advertisement for this vacancy (if a newspaper, please state which one)
Job Application Form - Part 2
Education and Training

Please give details of schools and colleges attended from age eleven, including part-time education and other courses. Please note you will be required to produce relevant evidence of qualifications attained.

Please provide any education or training details. Include dates, qualifications gained, grades attained etc.
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Other Information
Additional skills e.g. languages, sign language, keyboard skills
Please state type of licence
Current/Most Recent Appointment
Title of your current job
Start Date
Current Employer
Salary Range
Employer Address
Current Salary
Reason For Leaving
Permanent or Temporary contract
Notice Required
Main Responsibilities
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Job Related Training
Brief details and dates of any training courses attended, excluding further education.
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Current Memberships of Institutions/Professional Bodies
Please state level of membership, i.e. Graduate, Fellow and membership number
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Employment History
Please include details of your most recent employer, type of business, job title, dates, duties and reason for leaving.
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Supporting Information
Please use this section to explain why you are applying for the job. Concentrate on how your experience, training and personal qualities match the requirements of the job description and person specification.
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Activities and interests away from work, which may be relevant to the job applied for.
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Additional Information

The Rehabilitation of Offenders Act (only complete this section if instructed to do so on the job description and Person Specification enclosed with this form)

The Rehabilitation of Offenders Act allows for a person who has been convicted of a criminal offence involving a sentence of not more than 2 ½ years imprisonment and who has since lived trouble free for a specified period of time (related to the severity of the offence) to be treated as if the offence, conviction or sentence had never occurred. This is known as a spent conviction.

The job for which you are applying is one of those to which the provisions of the above Act in relation to spent convictions, do not apply. You must, therefore, disclose whether you have any previous convictions, whether or not they are spent.

Should you identify that you have a criminal conviction, this will be discussed in confidence at interview. However you should note that only convictions that are relevant to the job in question will be taken into account.

Have you any unspent convictions? If so please give details.
Conviction Details

If between the completion of this application form and taking up a job with Tarporley War Memorial Hospital you are convicted of a criminal offence you must inform Tarporley War Memorial Hospital Limited of this.

If you do not disclose any conviction you have, it could lead to your application being rejected, or, if you are appointed, may lead later to your dismissal.
People who have convictions will be treated fairly and given every opportunity to establish their suitability for the job.

Any information that you give will be kept in strict confidence and will be used only in respect of your application for this job.

Disclosure and Barring Service
Successful applicants will be asked to apply for a DBS check from the Disclosure and Barring Service.

Please check the Job Description and Person Specification to identify the level of check required for the position for which you are applying.

A copy of the Criminal Records Bureau Code of Practice is available on request.

urther information about the Disclosure process can be found at www.disclosure.gov.uk

Digital Signature

I certify that the details on this application form and any supplementary information attached are true as far as I know. I understand that if I give false information or withhold relevant information, it could result in my dismissal.

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