• MM slash DD slash YYYY
  • Please ensure you complete all sections of the Application Form.

  • SECTION 1 – Personal Details

  • SECTION 2 – GMC / GDC Registration

  • Fitness to Practise

  • SECTION 3 – Medical / Higher Education

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  • SECTION 4 – Additional Professional Qualifications

  • MM slash DD slash YYYY
  • Please provide FULL CAREER HISTORY – use a separate sheet if necessary
  • SECTION 5 – Current Employment Details

  • FromTo
  • SECTION 6 – Previous Employment Details

  • FromTo 
  • SECTION 7 – Achievements of Distinction / Prizes

  • MM slash DD slash YYYY
  • SECTION 8 – Publications

  • MM slash DD slash YYYY
  • SECTION 9 – Audit

  • MM slash DD slash YYYY
  • SECTION 10 Teaching Experience

  • SECTION 11

    Why have you chosen to apply for this post at Woking Hospice? (Maximum of 100 words)
  • SECTION 12 – Disclosure Information

    REHABILITATION OF OFFENDERS : Because of the nature of 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 Act 1974 (Exemptions) Order 1975. Applicants are, therefore, not entitled to withhold information about convictions which for other purposes are “spent” under the provision of the Act. In the event of employment, failure to disclose such convictions could result in dismissal or disciplinary action by the Trust. Any information given will be considered only in relation to posts to which the Order applies.
  • SECTION 13 – Referees

    Please give the name of your education supervisor or the person that most closely supervised your work during each of your most recent posts.
  • Previous employer / Educational Supervisor

  • Previous employer / Educational Supervisor


  • SECTION 14 – Declaration

  • If you are offered and formally accept a post you should not then withdraw unless the employer will have time to make other arrangements. (Good Medical Practice published by the General Medical Council.) Failure to comply with the requirement may result in a complaint to the GMC.

  • SECTION 15 – Signature

  • Please return the completed form along with accompanying Equal Opportunities Form to: Vanessa Pinto HR Administrator Woking & Sam Beare Hospice Hill View Road Woking Surrey, GU22 7HW  
  • Equal Opportunities Recruitment Monitoring

  • Please return one copy of this Form along with the copy of your application form.

    At Woking and Sam Beare Hospices we value the individual contribution of our employees irrespective of gender, age, marital status, disability, sexual orientation, race, colour, religion, ethnic or national origin. To help us monitor the effectiveness of our policy, please complete this form.

    The information will be used solely for monitoring purposes and treated as strictly confidential under the provisions of The Data Protection Act 1998. The personal information provided in your application will be processed and stored in accordance with The Data Protection Act 1998 and will not be released to any unauthorised person. This recruitment monitoring form will be separated from your application form before any shortlisting of candidates is undertaken. If you feel that your application for employment has been unfairly considered on any of the above grounds, complaints may be made in writing to the Director of Human Resources.

  • MM slash DD slash YYYY
  • Children & Carers

    The Equal Opportunities Commission recommends that information on children and dependents should be collected on monitoring forms, to ensure there is not discrimination against applicants with children or against carers.
  • Ethnic Origin

  • NB : These criteria are used by the Office of Population Censuses and Surveyors.
  • Citizenship

  • Disability