Patrons: Bill Beaumont, Mark Lawrenson & Tisha Merry Reg Charity No: 512186

Personal Details


Education and professional qualifications

All relevant qualifications. Please also indicate subjects currently being studied. All relevant qualifications disclosed will be subject to a satisfactory check.

Subject/Qualification Name of Establishment/Place of Study Grade/Result Year Obtained

Training courses attended

Training courses that you have attended or details of courses that you are currently undertaking, together with the date completed or to be completed.

Course Title Training Provider Duration (Dates From/To) Year Obtained

Membership of professional bodies

Any relevant professional registrations or memberships. If you are registered then please enter the details below; this information will be subject to a satisfactory check.

Professional Body Membership or Registration Type Membership/Registration Number Expiry/Renewal Date

If YES, to the above, please give details on a separate sheet of paper.

Employment Details

Please record below the details of your current employer, or most recent employer if you are not currently employed.

Previous Employment Details

Please record below the details of all previous employment, beginning with the most recent first. Up to 3 previous employments can be entered. If required, please provide additional information regarding your employment within the ‘Supporting Information’ section.

Previous employer 1

Previous employer 2

Previous employer 3

Supporting information

In this box please provide your reasons for applying for this post and additional information which shows how you match the person specification for the job. This can include relevant skills, knowledge, experience, voluntary activities and training etc. If relevant to the post for which you are applying, you should include details about research experience, publications or poster presentations, clinical care and clinical audit.


Please provide the names and full contact details of the two people who have agreed to supply references. References must include at least one employer and cover a period of three years employment and/or training history.

Please note that all reference requests will be followed up and verified following a verbal offer of employment.

Referee 1

Referee 2

Criminal Records

Rehabilitation of offenders act

This job may involve contact with patients. You must, therefore, declare any convictions you may have had including those considered as spent under the above act. Any information given is in confidence and considered only in relation to the job for which you are applying. For relevant posts, an enhanced disclosure and barring document will also be required.


Data Protection

Under the Data Protection Act you are advised that the details provided on this application form will be used only for the purpose of recruitment and will not be passed to any third parties without prior consent or if required by law. Your details will be stored both manually and electronically for a period of no more than 12 months, after such time all details will be removed. By signing this application form you are giving St. Catherine’s Hospice consent to process your details and approach your referees.

Equal Opportunities Monitoring Form

This is sensitive personal data and will be treated with the utmost confidentiality in line with the requirements of the Data Protection legislation. The data will only be used for general statistical and monitoring purposes. The data will not be taken into account in assessing information on your application form.

The information provided on this form will be used to monitor the diversity of St Catherine’s Hospice staff and to enable the Hospice to develop appropriate policies and procedures regarding Equal Opportunities.

Ethnic Origin

Ethnic origin is not about nationality, place of birth or citizenship. It is about colour and broad ethnic groups. UK citizens can belong to any of the groups indicated.

How would you describe your ethnic origin?

Advertising Effectiveness

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