Application Form

Application For Employment Form

The Ulster Independent Clinic
Thank you for your interest. Applicants will be assessed only on the information provided in the Application Form. Curriculum Vitae must not be submitted with your application. Failure to fully complete the application Form may cause your application to be rejected.
Job Applied For: (please select from current list of jobs advertised)*
How did you hear about this job?*
Please Specify:*
Personal Details
Full Name*

TitleFirst NameLast Name
Middle name(s):
Birth Date

DayMonthYear
Current Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Email Address*
example@example.com
Contact Phone Number:*
Format: 000000000000.
Contact Phone Number:*
Mobile:*
undefinedFormat: 00000000000.
Mobile: *
YesNo
Canvassing Will Disqualify
Education

Please give full particulars of all secondary level education qualifications (if none type n/a in box)*

Rows	Level Attained	Subject	Grade
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Please give full particulars of all further level educational qualifications (if none type n/a in box)*
Degree / Diploma/Certificate

Please specify and professional qualifications, Membership obtained including dates awarded. Applies to all staff..(if none type n/a in box)*

Rows	Name Professional Body / State Registration	Part No With Date & Result	Final No With Date & Result	Registration No Enrolment / Pin	Date Attained	Date Expired	Examinations Yet To Be Taken
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Additional Qualifications, Training and Apprenticeships relevant to this post (with date including any in progress) (if none type n/a in box)*

Employment History Present Post
EmployedUnemployed
Name Of Present Employer*
Date Appointed*

DayMonthYear
Date
Job Title*
Present Salary*
Notice Required*
Reason for Leaving*
Principle Duties Of Present Post*
Employment History Previous Posts
- Date From:
  
  DayMonthYear
  Date
- Date To:
  
  DayMonthYear
  Date
- Name of Employer:
- Address of Employer:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title:
- Salary:
- Duties:
- Reason For Leaving:
- Date From:
  
  DayMonthYear
  Date
- Date To:
  
  DayMonthYear
  Date
- Name of Employer:
- Address of Employeer:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title:
- Salary:
- Duties:
- Reason For Leaving:
- Date From:
  
  DayMonthYear
  Date
- Date To:
  
  DayMonthYear
  Date
- Name of Employer:
- Address of Employeer:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title:
- Salary:
- Duties:
- Reason For Leaving:
- Date From:
  
  DayMonthYear
  Date
- Date To:
  
  DayMonthYear
  Date
- Name of Employer:
- Address of Employeer:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title:
- Salary:
- Duties:
- Reason For Leaving:
- Date From:
  
  DayMonthYear
  Date
- Date To:
  
  DayMonthYear
  Date
- Name of Employer:
- Address of Employeer:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title:
- Salary:
- Duties:
- Reason For Leaving:
- Date From:
  
  DayMonthYear
  Date
- Date To:
  
  DayMonthYear
  Date
- Name of Employer:
- Address of Employeer:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title:
- Salary:
- Duties:
- Reason For Leaving:
- Date From:
  
  DayMonthYear
  Date
- Date To:
  
  DayMonthYear
  Date
- Name of Employer:
- Address of Employeer:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title:
- Salary:
- Duties:
- Reason For Leaving:
- Date From:
  
  DayMonthYear
  Date
- Date To:
  
  DayMonthYear
  Date
- Name of Employer:
- Address of Employeer:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title:
- Salary:
- Duties:
- Reason For Leaving:

Skills and Experience to Date
Candidates only need to list the elements to be tested via the application form as per the candidate information booklet. Please provide individual examples relevant to each essential and/or desirable criteria the candidate is able to demonstrate.*
Additional Information
You must have the legal right to work in the UK and in line with its legal obligations Ulster Independent Clinic will carry out Right to Work documentation checks prior to appointment. This will include checking documentation for those with Settled or Pre Settled status under the EU Settlement Scheme. Please note that whilst we welcome all applications regardless of national origin we do not hold a UK Home Office Sponsor Licence and we are therefore unable to sponsor applicants under the new UK Home Office points based immigration process.
YesNo
Please give details*
Policy on the Recruitment of Ex-Offenders
All successful applicants will be subject to Access NI vetting. A criminal record will not necessarily be a bar to applicant obtaining a position. Applicants can access the Clinic's policy on the recruitment of Ex-Offenders on the Clinic's following web page
https://ulsterindependentclinic.com/jobs/policies alternatively applicants can request a paper copy to be sent to them.
Positions within the Clinic which involve direct patient care are classified as regulated. It is therefore necessary to ask the question.
YesNo
Please give details below*
Under the Rehabilitation of Offenders (Exceptions) Order NI, 1979, The Ulster Independent Clinic is included in the list of exempted employments. As such, any criminal conviction may never be regarded as spent and must be disclosed when applying for a post.
IT IS THEREFORE NECESSARY TO ASK THE QUESTION:-
YesNo
Please provide details*
Failure to disclose such information as detailed above could result in dismissal.

Unprejudiced consideration will be given to candidates who declare criminal conviction(s) unless their offence(s) is/are manifestly incompatible with the post in question

References
Please give the names and addresses of the two persons not related to you from whom references may be sought. One of these MUST be your present or past employer who has knowledge of you in a work situation and is able to comment on your ability to carry out the particular tasks of the job for which you have applied for. Candidates applying for their first job should give the name and address of their head teacher or a lecturer.
Company Name*
Company Name*
Name*

First NameLast Name
Name*

First NameLast Name
Job Title*
Job Title*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Email*
example@example.com
Phone Number*

Area CodePhone Number
Phone Number*

Area CodePhone Number
Occupation*
Occupation*
If you have not named your current employer (or if unemployed your previous) please state why*
Please note that references will only be sought post interview if the panel is considering offering you an appointment.

I hereby declare that to the best of my knowledge the above information is true and accurate.

I hereby understand and consent to my data being processed in accordance with Data Protection Legislation.
Signature*
Date*

DayMonthYear
Date
NOTE A CANDIDATE FOUND TO HAVE KNOWINGLY GIVEN FALSE INFORMATION OR TO HAVE WILFULLY SUPRESSED ANY MATERIAL FACT. MAY LIABLE TO DISQUALIFICATION OR, IF APPOINTED, TO DISMISSAL
Should be Empty:

Application For Employment Form