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Contact Details
Prefix
Mr.
Mrs.
Ms.
Mx.
Miss
Dr.
Prof.
First Name
*
Last Name
*
Street Address
*
City
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Australia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
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Falkland Islands
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France
France, Metropolitan
French Guiana
French Polynesia
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Gabon
Gambia
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Ghana
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Grenada
Guadeloupe
Guam
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montserrat
Montenegro
Morocco
Mozambique
Myanmar
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Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana Islands
Norway
Oman
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Palestine, State of
Panama
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Paraguay
Peru
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Poland
Portugal
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Reunion Island
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
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San Marino
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Saudi Arabia
Senegal
Serbia
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Sierra Leone
Singapore
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Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
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Stateless Persons
Sudan
Sudan, South
Suriname
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Sweden
Switzerland
Syria
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Tajikistan
Tanzania
Thailand
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Tokelau
Tonga
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Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
US Minor Outlying Islands
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen Arab Rep.
Yemen Democratic
Zambia
Zimbabwe
Phone
*
Email Address
*
Position
Position applied for
*
How did you hear about the position?
*
Are you applying for
*
Full-time position
Part-time position
Day work
Night work
Bank
Driving
Do you hold a full UK or European Economic Area (EEA) driving licence?
*
Yes
No
If yes, has your driving licence been endorsed?
*
Yes
No
Do you have a vehicle you can use for business purposes if required?
*
Yes
No
If yes, please explain
*
Full Employment History
Please list below your complete and full employment history, explaining all employment gaps, starting with your most recent employer, working backwards to when you left full-time education (continue on a separate sheet if necessary). Please also attach a full CV (if possible).
Full CV
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Employer 1
Employer's name
Reference Details
Street Address
Phone
Email Address
Job title and main duties
Position
Salary
Start Date
End Date
Start Date End Date Notice period
Reason for leaving
Employer 2
Employer's name
Reference Details
Street Address
Phone
Email Address
Job title and main duties
Position
Salary
Start Date
End Date
Notice period
Reason for leaving
Employer 3
Employer's name
Reference Details
Street Address
Phone
Email Address
Job title and main duties
Position
Salary
Start Date
End Date
Reason for leaving
Education
Secondary School (name and address)
Qualifications gained
Start Date
End Date
Further Education
Further Education e.g. college / university
Qualifications gained
Start Date
End Date
Qualifications and Training
Please give details of any professional qualifications gained
Are you undertaking any course of study at present?
Yes
No
Character References
Please provide details of two people who can be contacted for a reference if you have not provided a full 5 year work history. The referee must be able to comment on your suitability and character for the post you have applied for (e.g. fellow work colleague or course tutor). Relatives and/or Partners should not act as referees. Referees will not be contacted without your consent.
Reference 1
Contact Name
Job Title
Street Address
Phone
Email Address
Relationship to you
Number of years known
Reference 2
Contact Name
Job Title
Street Address
Phone
Email Address
Relationship to you
Number of years known
Additional Skills
Please use the space below to explain why you have applied for this vacancy. You should include details of your experience, skills and personal qualities that you can bring to this role. Please continue on a separate sheet if you need to (please put your name at the top of the sheet). You will need to refer to the enclosed job description and person specification when completing this section.
Please submit a copy of your resume
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Eligibility to work in the UK:
Do you have the right to work in the UK?
Yes
No
Please provide details of your visa and any restrictions in the space provided below (if applicable)
Other Employment
To allow us to monitor your working hours and comply with current legislation, please complete the following section:
If you are successfully appointed to the post applied for at Vitality Healthcare, do you intend to continue with other employment?
Yes
No
Disclosure of criminal record information
Due to the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitation of Offenders 1974 (Exceptions) Order 1975.
This means that convictions that are ‘spent’ under the terms of the Rehabilitation of Offenders Act 1974 must be disclosed and will be taken into account in deciding whether to make an appointment.
Any information will be completely confidential and will be considered only in relation to this application.
Please read the above carefully and then answer the following questions:
Have you ever been convicted of a criminal offence?
Yes
No
Have you ever received any official cautions, reprimands or warnings?
Yes
No
To your knowledge, are you currently the subject of any criminal proceedings or any police investigation?
Yes
No
Data Protection:
The Vitality Healthcare Privacy Statement is available on our website (www.vitalityhealthcare.net) or a copy can be requested from the Human Resources Department. Please confirm you have accessed the Vitality Healthcare Privacy Statement and you have read, understood and agree to all the terms stated.
I confirm that i have understood the private policy
Date
Declaration:
I declare that the information given in this application is to the best of my knowledge, complete and correct. I accept that should any statement made by me in connection with this application be found to be false, incomplete or misleading then the application shall be void and consequently, Vitality Healthcare may terminate any contract arising at any time.
I confirm that i have understood the private policy
Date
SUBMIT