Radiographer(Ref: )

Personal Details (1/8)

First Name:

Surname:

Known As:

Email Address:

Address:

Postcode:

Mobile Number:

Home/Alternative Number:

National Insurance Number:

Professional Registration Details:

Body (NMC/HCPC/GPC):

Pin/Registration No:

Expiry date:

Membership of professional body

Body:

Reg No:

Additional Information

Do you require a work permit?

YesNo

If yes, please could you provide additional information.

Do you require any reasonable adjustments to be made should you be invited to attend an interview?

Do you hold a current full UK driving licence?*

YesNoN/A

*Please note that this is only relevant if driving is included in the role you are applying for

Your Application (2/8)

Application for the post of:

At which facility:

How did you become aware of the vacancy?:

Are you seeking:

Full TimePart TimeBank Work

Are you fully flexible in your working days/hours/pattern:

YesNo

If "No", please provide details:
What is your notice period?:

What date are you available to start work from:

Please confirm your interview availability:

Do you know anyone who currently works for Aspen Healthcare?

YesNo

If "Yes", who?:

Have you applied to work for Aspen Healthcare before?

YesNo

If "Yes", please provide details:

Have you ever worked for Aspen Healthcare before?:

YesNo

If "Yes", please provide details:

Education & Qualifications (3/8)

Please list your schools, colleges & universities:
Dates

Name of school/college/university

Qualifications/grade obtained

Dates

Name of school/college/university

Qualifications/grade obtained

Dates

Name of school/college/university

Qualifications/grade obtained

Dates

Name of school/college/university

Qualifications/grade obtained

Dates

Name of school/college/university

Qualifications/grade obtained

Dates

Name of school/college/university

Qualifications/grade obtained

If you have attended training courses relevant to the post you are applying for, please provide details:
Dates

Name of training provider

Name of course attended

Dates

Name of training provider

Name of course attended

Dates

Name of training provider

Name of course attended

Dates

Name of training provider

Name of course attended

Dates

Name of training provider

Name of course attended

Dates

Name of training provider

Name of course attended

Employment (4/8)

Current/most recent employer

Company Name:

Website:

Position Held:

Line manager's name:

Address 1:

Address 2:

Town/City:

Postcode:

Start date:
Leaving Date:
Salary:

Reason for Leaving:

Please give a brief description of your current duties and responsibilities

Previous Employer

Company Name:

Website:

Position Held:

Line manager's name:

Address 1:

Address 2:

Town/City:

Postcode:

Start date:
Leaving Date:
Salary:

Reason for Leaving:

Please give a brief description of your current duties and responsibilities

Previous Employer

Company Name:

Website:

Position Held:

Line manager's name:

Address 1:

Address 2:

Town/City:

Postcode:

Start date:
Leaving Date:
Salary:

Reason for Leaving:

Please give a brief description of your current duties and responsibilities

Previous Employer

Company Name:

Website:

Position Held:

Line manager's name:

Address 1:

Address 2:

Town/City:

Postcode:

Start date:
Leaving Date:
Salary:

Reason for Leaving:

Please give a brief description of your current duties and responsibilities

Previous Employer

Company Name:

Website:

Position Held:

Line manager's name:

Address 1:

Address 2:

Town/City:

Postcode:

Start date:
Leaving Date:
Salary:

Reason for Leaving:

Please give a brief description of your current duties and responsibilities

Previous Employer

Company Name:

Website:

Position Held:

Line manager's name:

Address 1:

Address 2:

Town/City:

Postcode:

Start date:
Leaving Date:
Salary:

Reason for Leaving:

Please give a brief description of your current duties and responsibilities

*Professional Referees

Additional Information

Where there are gaps in your employment history, please provide full details here including dates:

Aspen Healthcare’s Values & Mission Statement (5/8)

Our mission is to provide first-class independent healthcare for the local community in a safe, comfortable and welcoming environment; one in which we would be happy to treat our own families.

As part of this, our employees are encouraged to embrace our values in everything they do.

  1. Beyond Compliance
  2. Personalised Attention
  3. Partnership & Teamwork
  4. Investing in Excellence
  5. Always with Integrity

Referees (6/8)

Please provide your referee details covering at least the last 5 years. This must include your current/most recent employer.
Where there are breaks in your employment please provide details of a personal referee*.

*Please note that personal referees should only be provided in instances where no professional references can be obtained

Do you consent to references being obtained prior to interview?:
YesNo

Professional Referees

Referee 1
Name

Job Title:

Company Name:

Address 1:

Address 2:

Town/City:

Postcode:

Email Address:

Contact Number:

Employment dates from:
To:

Relationship to you:

Referee 2
Name

Job Title:

Company Name:

Address 1:

Address 2:

Town/City:

Postcode:

Email Address:

Contact Number:

Employment dates from:
To:

Relationship to you:

Personal Referees (Where applicable)

Referee 1
Name

Job Title:

Company Name:

Address 1:

Address 2:

Town/City:

Postcode:

Email Address:

Contact Number:

Employment dates from:
To:

Relationship to you:

Referee 2
Name

Job Title:

Company Name:

Address 1:

Address 2:

Town/City:

Postcode:

Email Address:

Contact Number:

Employment dates from:
To:

Relationship to you:

Disclosure (7/8)

This section of the application form will only be viewed by those who need to see it as part of the recruitment process. Any information disclosed will be treated with the strictest of confidentiality.

Depending on the role you are applying for, Aspen Healthcare may be required to apply for a Disclosure and Barring (DBS) check or where relevant, a Disclosure Scotland (DS) check. The level of check obtained will depend on the role requirements and if the position conducts ‘Regulated Activity’.

Under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, some professions within the health and care sectors are exempt from Section 4 (2) and applicants are therefore not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act.

If you have a criminal record and:

  • are unsure about what might be revealed about you as part of a DBS/DS check;
  • unsure about the type of information you should consider declaring when completing the application form or;
  • need some further guidance please contact the local facilities Human Resources Department for assistance and obtain a copy of Aspen Healthcare’s Recruitment of Ex-Offenders Policy Statement (GP-PERS50) for further clarity.

Aspen Healthcare will only take into account relevant criminal records and information that is relevant to the position being applied for. Failure to make adequate disclosures could result in disciplinary action up to and including dismissal or your application being withdrawn from the recruitment process.

Do you have a criminal conviction that has been issued in this or any other country?

YesNo

Have you been (or are you currently) part of any police investigation that could result in a conviction in this or any other country?

YesNo

Have you been (or are you currently) the subject of fitness to practice proceedings by any licensing or regulatory body in this or any other country?

YesNo

Where you have answered yes to any of the above, please provide us with some additional information including; the details of the conviction, penalty, sentence or order of the Court and also the date of the offence.

Please also include any additional information that you believe to be relevant.

Declaration

I understand that appointment, if offered, will be subject to the information given on this form being correct and that failure to disclose accurate information will disqualify me from consideration as will my failure to disclose pertinent facts relating to my previous employment. I also understand that my appointment is subject to satisfactory pre-employment checks including an occupational health assessment, DBS/DS check (if required)and satisfactory references You are required to acknowledge by signing below your agreement and understanding of these statements.

Aspen Healthcare Ltd is an equal opportunities employer and as an employee, you will be required to pursue your duties in accordance with its Equal Opportunities Policy.

You are required to acknowledge by signing below your agreement and understanding of these statements.

Signature:

Date:

Additional Information
Where needed, please use this section to provide additional information:

Equality Opportunities Recruitment (8/8)

Equality Opportunity Recruitment Monitoring form - Confidential

This section of the application form will be detached from your application and will not be used as part of the selection process nor will it be seen by anybody who is interviewing you.

Aspen Healthcare Ltd is committed to promoting equality, diversity and an inclusive and supportive environment for all current and prospective employees.

In particular, Aspen Healthcare Ltd seek to ensure a diverse working environment in which people are treated equitably regardless of their gender, race, colour or national origins, age, disability, socio-economic background, religious or political beliefs and affiliations, marital status, family responsibilities, sexual orientation or other inappropriate distinction.

In order to ensure that Aspen Healthcare Ltd are promoting fair recruitment, it is necessary to collect information from all employees and job applicants on the key characteristics which relate to equality and diversity in employment.

The data collected will be anonymised and used for monitoring purposes under the terms of the General Data Protection Regulation 2018. The information will be used to form baseline statistical reports to assess the impact of our policy and for the purpose of adhering to third party reporting requirements.

Section 1: Personal Details
First Name:

Surname:

Date of birth:

Post applied for:

Section 2: Disability
Under the Equality Act 2010 the definition of disability is if you have a physical or mental impairment that has a ‘substantial’ and ‘long-term’ adverse effect on your ability to carry out normal day to day activities.

According to the definition outlined above, do you consider yourself to have a disability?

YesNoPrefer not to say

Section 3: Nationality
Please specify your nationality:
Prefer not to say

Section 4: Ethnicity
You are asked to classify yourself in the category which you feel most closely describes your origin. If none of the specific groups are suitable, please mark the relevant ‘other’ and specify your ethnicity.

A. White

B. Mixed

C. Asian or Asian British

D. Black or Black British

E. Chinese or other ethnic group

F. Other ethnicity than those listed in A-F:

G. Prefer not to say:
Prefer not to say

Section 5: Religion
Please select your religion:

Section 6: Gender
Please specify your sex:

Section 7: Sexual Orientation
Please specify your sexuality:

Section 8: Martial Status
Please specify your martial status:

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