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Job Application Form

Job Application Form
Part A: Personal Details
(Eg. Mr, Mrs, Miss, Ms, Dr)
Please note that correspondence will be via email whenever possible
Part B: Present (or most recent) Employer
Part C: Employment History (most recent first)

Please give as much relevant information as possible. For posts working with children and vulnerable adults you must give your full employment history from when you left school/higher education and explain any gaps in your employment and include date

Part D: Academic, Professional and Vocational Qualifications

*For posts working with children/vulnerable adults you must provide all dates

Part E: Training/Continuing Professional Development

Please give details of relevant training/development activities.

Part F: Personal Statement
Referring to the person specification, provide examples of how you have demonstrated the key competencies and the knowledge and skill requirements for this role. You may use experience gained from within and/or outside the workplace to provide these examples. (We recommend that you use the different headings on the person specification as a starting point.)
Please describe ways in which you have demonstrated the personal attributes required for this post, as outlined in the person specification.
Part G: Supplementary Information

Personal Transport: For posts which involve travel away from normal place of work:

Positive About Disability: We welcome applications from people with disabilities. Wherever possible we will make reasonable adjustments to enable a person with a disability to access the application and appointment process fairly.

Disclosure of Criminal Offences: The Rehabilitation of Offenders Act 1974 gives individuals the right not to disclose details of old offences which are seen as ‘spent’

Nurses only:

Doctors only:


References: Please provide the names of two professional referees, both of whom can write with authority about your performance, abilities and competence in a work, voluntary or educational environment. The first reference must be your manager or a senior manager representing your current or most recent employer. References will not be accepted from colleagues, relations or people who know you solely as a friend. If you do not wish your current employer to be contacted prior to interview please tick the box below, unless you are applying for a post working with children as below. Please note that if you are successful at interview and are conditionally offered and accept the post, we will commence pre-employment checks which will include contacting ALL referees.

If you are applying for a post working with children or vulnerable adults Your first referee must be a manager representing your current/most recent employer. If this post has not involved working with children or vulnerable adults but a previous post has, that previous employer must be given as your second referee. This applies even if you have done other work in between. *For these posts, all references will be requested before interview.

Dates of your employment

Dates of your employment

Declaration of Interest:

(Failure to disclose a relationship may disqualify a candidate and, if appointed, may render him/her liable to dismissal)


Upon receipt of your application form, Burnham & Berrow Medical Centre will be the Data Controller of your personal data. Burnham & Berrow Medical Centre will hold all the information you have given on this application form for legal requirements and for the purposes of personnel administration and statistical analysis. Your information will be held on a manual file and will also be entered in its current or altered format onto the Practice’s computerised database. No information may be passed onto a third party unless contracted to Burnham & Berrow Medical Centre for specific employment services without your express agreement unless required by law. Your signature on the Declaration below indicates your agreement to this section.

Immigration, Asylum and Nationality Act 2006

Under the Immigration, Asylum and Nationality Act 2006, you are required to provide evidence of your right to work in the UK. If called for an interview you will be advised of the documents you will need to provide which will then be checked to ensure the Practice complies with current legislation


• I confirm that I am entitled to live and work in the United Kingdom. • I am willing for this data to be held and processed by Burnham & Berrow Medical Centre and to be verified with relevant third parties. This may include previous employers. • The information on this form is accurate. I understand that providing false information is an offence and may lead to my application being disallowed or, should I be appointed, to my dismissal and, where appropriate, may be referred to the police. • I understand that employment will be subject to receipt of satisfactory references and medical clearance

If you apply online and are shortlisted, you will be asked to sign your application at interview.


Equal Opportunities - Recruitment Monitoring

This form will be kept separate from your application form. It is not referred to during the selection process

Burnham & Berrow Medical Centre values diversity and is committed to promoting equality of opportunity for our employees and job applicants.

We monitor our recruitment and selection practices to fulfil our statutory duty relevant to equality in employment and to ensure our practices are fair, equitable and consistent with the aim of appointing the best person for the job. Recruitment monitoring enables us to take active steps to promote better policy and organisational practice.

The information you supply on this questionnaire will be recorded confidentially on our HR Systems and held for a maximum of 12 months. During this time it will be used solely for the purposes of monitoring the profile of our job applicants. Access to the data will be restricted to nominated staff responsible for HR within the Practice.

If you are appointed, the data will also be used for our HR/Payroll records purposes, which includes another legal requirement, workforce monitoring. We aim to ensure all a


This information will be treated in the strictest confidence

Are you?
How would you describe your ethnic origin?
Do you consider yourself to have a disability or impairment?
Which Religious Group do you belong to?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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