APPLICATION FORM

PLEASE FILL IN ALL SECTIONS

1. Personal details and Information (to be completed in block capitals please)

Job Application Reference (If applicable):

Position applied for:

Branch/Location:

Where did you see this post advertised?:

Forename/s*:

Surname*:

Date of Birth*:

NI No:

Address*

Postcode:

Home Tel No:

Mobile Tel No*:

Your email*:

2. Additional Information

Do you possess a valid UK driving licence?*:
YesNo

Do you have use of a car for work?*:
YesNo

Do you have the legal right to work in the UK?*:
YesNo

If ‘Yes’ but there are conditions attached, please specify (e.g. start/finish/WRS etc) If ‘No’ please note that we are unable to recruit anyone who does not have the legal right to work in the UK.:

Are you related to or do you know anyone who works for Allot Healthcare Services Ltd?*:
YesNo

If Yes, please give the name of the employee and the relationship to them:

Do you have any other work commitments, either paid or unpaid, which you would wish to continue with if offered employment by Allot Healthcare Services? If Yes, please give details at the interview stage*:
YesNo

Criminal Record Declaration - PLEASE READ THIS CAREFULLY

The nature of the position for which you have applied is exempted from the Rehabilitation of Offenders Act 1974.

This means that you must declare all criminal convictions, including those that would otherwise be considered “spent”. Answering ‘Yes’ to any of the questions below will not necessarily bar you from appointment. This will depend on the nature of the position for which you are applying and your particular circumstances.

Have you ever been convicted of a criminal offence?*:
YesNo

Have you ever received any official cautions, reprimand or warning?*:
YesNo

To the best of your knowledge, are you currently the subject of any criminal proceedings or nay police investigation?*:
YesNo

If you have answered ‘Yes’ to any of the above 3 questions please provide details below:

4. Education, Training, Qualification and Current Learning

What is your highest level of education?*
—Please choose an option—High SchoolCollegeDiplomaHigh School GraduateTrade/Technical/Vocational TrainingAssociate DegreeBachelor’s DegreeMaster’s DegreeProfessional DegreeDoctorate DegreeOther

Please List all Past Secondary Education (Include Institution, Level, Awards and Dates)

Please List all Past Further/Higher Education (Include Institution, Level, Awards and Dates)

Other relevant Training, Qualifications or work related skills (including dates)

Other relevant training, professional qualifications or work related skills (including dates):

Any details of membership to professional bodies (please provide details):

FOR NURSES ONLY

Skills

Please tick the area you have experience in:

A & EAnaestheticsAnte NatalBirthCardiacCardiac Cath LabCCUCDUChemoDialysisECGElderlyEndocrineEndoscopyGynaeHaematologyHealth VisitorITU/HDUIV’sMedicalNICUOncologyOrthopaedicsOutpatientsPaedsPICUPlastering & SuturingPost NatalRecoveryScrubSubstance MisuseSurgicalTSSUVenepuctureVentilation for PaedsCannulation

By selecting the above information you are stating your clinical ability to work in those areas. Should it be found that you are clinically unable to work in those areas, you accept that the company may take disciplinary action against you.

Please tell us about your nursing relevant experience, skills, knowledge and competencies which you feel make you suitable for this job. Give examples of things you have done in your work life. Please use additional paper is necessary:

6. Employment History

Employment History

Please provide details of all of your employment history covering the last 10 years where applicable. If you do not have ten years employment history, then please enter your employment history since leaving school.

Employment History (Recent/Current)

Employer

Start Date

End Date

Job Title

Brief Description of Duties

Reason for Leaving

Employer Address

Employer Telephone

Employer Email

Manager/Supervisor Name

Can we contact this employer for a reference?
YesNo

Employment History 2

Employer

Start Date

End Date

Job Title

Brief Description of Duties

Reason for Leaving

Employer Address

Employer Telephone

Employer Email

Manager/Supervisor Name

Can we contact this employer for a reference?
YesNo

Employment History 3

Employer

Start Date

End Date

Job Title

Brief Description of Duties

Reason for Leaving

Employer Address

Employer Telephone

Employer Email

Manager/Supervisor Name

Can we contact this employer for a reference?
YesNo

Employment History 4

Employer

Start Date

End Date

Job Title

Brief Description of Duties

Reason for Leaving

Employer Address

Employer Telephone

Employer Email

Manager/Supervisor Name

Can we contact this employer for a reference?
YesNo

Employment History 5

Employer

Start Date

End Date

Job Title

Brief Description of Duties

Reason for Leaving

Employer Address

Employer Telephone

Employer Email

Manager/Supervisor Name

Can we contact this employer for a reference?
YesNo

Other Employment History

Please List All Other Previous Employment (stating Employer, Employment Dates, Your Duties)

Employment Gaps

Please provide explanations for any gaps in employment.

7. Relevant Experience

Please use this space to state how your skills, experience and training would enable you to meet the requirements of the role for which you are applying. Please make references to the person specification. Please use a continuation sheet if necessary:

8. Availability (only complete this section if you are applying for a Care Worker position)

Mon - Fri (Mornings)Mon - Fri (Afternoons)Mon - Fri (Evenings)Mon - Fri (Sleep Over)Mon - Fri (Waking Nights)Saturday (Mornings)Saturday (Afternoons)Saturday (Evenings)Saturday (Sleep Over)Saturday (Waking Nights)Sunday (Mornings)Sunday (Afternoons)Sunday (Evenings)Sunday (Sleep Over)Sunday (Waking Nights)

Geographical area(s) you are interested in working?:

The work you are interested in?:

Personal CareDomestic Care

Ideal number of hours you would like to work per week?:

References

Please provide the names and contact details of at least three referees, the first two must be your present or most recent employer who can provide information relating to your competency in a caring role. If there is less than two years between both of these then please provide two further references. We will not contact any referee without your permission or until an offer of employment has been accepted, however if you are applying for a post which requires unsupervised access to children/vulnerable adults, the company reserves the right to approach any past employer for a reference. If you do not have three employment references, one may be from a professional body, a lecturer or similar.

Reference 1

Name:

Surname:

Title/Position:

Organisation:

Address:

Postcode:

Relationship to applicant:

Email:

Telephone Number:

May We Contact Them Prior To Interview?
—Please choose an option—YesNo

Reference 2

Name:

Surname:

Title/Position:

Organisation:

Address:

Postcode:

Relationship to applicant:

Email:

Telephone Number:

May We Contact Them Prior To Interview?
—Please choose an option—YesNo

Reference 3

Name:

Surname:

Title/Position:

Organisation:

Address:

Postcode:

Relationship to applicant:

Email:

Telephone Number:

May We Contact Them Prior To Interview?
—Please choose an option—YesNo

10. Applicant Declaration (please read carefully before signing the application)

1) The information in this form is true and complete. I agree that any deliberate omissions, falsification or misinterpretation on this form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This equally applies to any medical questionnaires I may complete.

2) I confirm that I have not been subject to any cautions or convictions (other than those given above), investigation, disciplinary action, or enquiry into adult/child protection matters or inappropriate behaviour, and that the information I have given in the criminal record declaration section is to best of my knowledge.

3) Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that this company reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my personal file during employment and for up to six years thereafter and understand that information will be processed in accordance with the Data Protection Act 1998

I consent to my data being collected, processed and stored from this form in accordance with the relevant Data Protection and Processing laws. Please tick to acknowledge that you have read our Privacy Policy.

Applicant Name:
Date Completed:

Please click submit below to submit your application form

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