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This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Application Form 2014 – Draft
Document Control
The annual review of the national application form was reviewed by the
Application Form Group.
Change Record
Date
Author
Version
29/05/2013
JH
0.1
29/05/2013
CK
0.1
29/05/2013
29/05/2013
05/06/2013
06/06/2013
25/06/2013
26/07/2013
05/08/2013
DS
SH
JM/JA
BW
JM
JH
SH
0.1
0.1
0.2
0.3
0.4
1.0
1.0
12/08/2013
JM
1.1
Change
Combined form with changes from App
Group meeting
Changes to ICM and dual training
questions
Changes to applicant declaration section
Edit to career gap section
Immigration section changes
Changes following PAG
Immigration section changes
ALS Addition and typos
Various edits, especially to GMC and
foundation competency sections
Changes to immigration.
Reviewers
Name
Vicky Ridley-Pearson (VRP)
Jane Appleyard (JA)
Stephen Harding (SH)
Joanna Carroll (JC)
Clare Kennedy (CK)
Matthew Huggins (MH)
Tanya Rehman (TR)
Clare Kerswill (KW)
James Fenton
Jonathan Howes (JH)
Daniel Smith (DS)
Benjamin Witton (BW)
Organisation
HEE Kent Surrey and Sussex
London Shared Service
RCP
RCPsych
HEE West Midlands
RCOG
RCPCH
HEE North West
NIHR
Health Education England
General Medical Council
Health Education England
1
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
SAMPLE NATIONAL APPLICATION FORM FOR ALL
LEVELS OF SPECIALTY RECRUITMENT 2014
The information you enter on this Part One form will be passed direct to the recruiting
department at the postgraduate LETB/ DEANERY or national recruiting organisation. It will
not be used in assessing and scoring your application. If you are successful the details
entered in this part of the application form will then be passed to the HR department of your
prospective employer.
Please note: incomplete application forms will not be considered.
I confirm that I have read the above statement and understand the implications if I do not
complete this application form correctly
I have read the Specialty Applicant Guide and understand the specialty entry and person
specification for the training programme I have chosen. See [URL]
* Denotes a mandatory field
PART ONE
Contact Information
Surname/Family
Name*
First Name*
Middle Name
Preferred Name
Name in which you are registered with
the GMC (or GDC) if different from the
above
Title* (Drop down
list)
Date of Birth
(dd/mm/yyyy)*
Address Line 1*
Address Line 2*
N.I Number
Address Line 3
Post Code*
Country*
Home Telephone*
Mobile
Telephone* (must
Work Telephone
Please indicate your preferred telephone
number*
Email Address1*
be entered with no
symbols)
May we contact
you at work?
Home
Yes
No (dropdown list)
Work (dropdown list)
Mobile
Please note: Most recruitment communications will
be via email so you must provide an active email
address which you check regularly. You must
inform the recruiting LETB/ DEANERY of any
change.
Personal Details
Do you currently hold a National Training Number (NTN)*?
1
Yes
No
See advice in the Applicant Guide concerning the best email addresses to use in your application form
2
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
If yes, which specialty and LETB/ DEANERY?
(dropdown list)
What is your NTN
___/___/___/_
Are you pursuing dual training with your current specialty with
this application?
Are you a member of the PVG
Yes
No
N/A
Scheme?
(only relevant for applicants to
Do
you have a disability which requires any specific
Scotland)
arrangements / adjustments to enable you to attend an
interview, assessment or other selection process?
Yes
No
If yes, what is your
membership number?
Yes
No
N/A (dropdown list)
If yes, please supply details below of what those specific arrangements / adjustments are* (mandatory if yes
above)
If you have a disability, provided you meet the minimum
criteria as specified in the Person Specification, do you wish
to be considered under the *Guaranteed Interview Scheme?*
(Please refer to the applicant guide for the relevant specialty
for further information)
Yes
No
N/A (dropdown list)
If you tick yes please give details below
Do you wish to be considered for less than full-time training
(LTFT)?
This information will not be made known to the selection panel but you will
need to apply formally for less than full-time training via the LETB/ DEANERY.
If you are working LTFT or need to do so for well-founded personal reasons
you must notify the LETB/ DEANERY of your intention to work LTFT and this
will be considered against the national eligibility criteria for LTFT training. The
recruiting Postgraduate LETB/ DEANERY aims to offer support to all trainees
who meet the national eligibility criteria to train LTFT; however trainees must
be appointed to a Full Time programme to be able to progress their LTFT
training application.
Yes
No (dropdown list)
For more details about LTFT training in the LETB/ DEANERY, including
information about eligibility and the application process, please refer to the
Less than Full Time Training web pages of your chosen LETB/ DEANERY. (Link
inserted here to:
Programme Specific Information
Do you wish to apply for a deferred start date? *
The start of training can only be deferred on statutory grounds (e.g.
Maternity Leave, ill health).
If yes, please enter the reason* max 100 words
Date available to start post (if this is later than the
advertised starting month and year of appointment)(Please
give reasons):
3
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Eligibility
Professional Registration
Do you have FULL registration with a
Licence to Practise awarded by the UK
GMC?*
Yes
GMC Reference
No.*
No
If yes, display the GMC reference number and registration
date fields
System to
ensure
correct
format
Date
of
registr
ation
If no, display question below
Please explain why you think you will be able to gain full UK GMC registration by time of appointment 2: (max
100 words)*
If applying to OMFS or dentistry , give
equivalent GDC registration information
here
Other Professional Registration(s)
Date of
registration
Free Text
Awarding Body
Free Text
Awarding Body
Language Skills
As a doctor or dentist, you are required to demonstrate skills in written and spoken English which allow you to
perform your clinical skills safely and to communicate effectively on medical and/or health topics with patients,
colleagues and the public.
Evidence of English language proficiency (please check all boxes that apply to you)
1. Was your undergraduate training in
English?*
2. Have your language skills been
tested through the 3IELTS
(International English Language
Testing System)* to at least the
minimum overall score required as
per the Person Specification4?
Date IELTS taken (dd/mm/yyyy)* (compulsory
if yes to above)
Yes
No (dropdown list)
If yes, please go to the next section
Yes
No
(dropdown
list)
If yes, please
enter scores and
date taken and go
to Q3.
If no, please go to
Q3
Overall Score
Speaking Score
Listening Score
Reading Score
Writing Score
__/__/____
NB: Documentation must be uploaded to your
application and provided at interview
3. Have you worked in UK NHS for 2 years
or more?
(Compulsory if no to ‘Was your undergraduate training
taught in English?’)
Yes
No If yes, please go to next section
NB: You must provide evidence of this at your interview
2
Time of appointment is the start date of the post/programme to which you are applying
See advice in the Applicant Guide for more information on the IELTS test
4
The Applicant must have achieved as a minimum the following scores in the academic lnternational English
Language Testing System (IELTS) in a single sitting within 24 months at time of application – Overall 7, Speaking 7,
Listening 7, Reading 7, Writing 7
3
4
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
4. Can you provide testimony from a UK
consultant relating to your English
language proficiency?
(Compulsory if no to ‘Have you worked in UK NHS for 2
years or more?’)
Yes
No If yes, please go to next section
NB: Documentation must be uploaded to your application and provided at
interview
5. Other – please provide evidence below of your English language proficiency (max 50 words)*
(Please refer to the applicant guide for further information)
Right to Work in the UK
Your eligibility to apply for this position will be determined by your immigration status on the closing date
for applications for this post. Some applicants may be considered before others on the basis of
immigration status, in accordance with the Immigration, Asylum and Nationality Act 2006.
If you are invited to interview, you will be required to produce the original documents (passport with appropriate visa
or biometric residence permit and any relevant correspondence with UK Border Agency 5) on the interview day.
Failure to provide evidence could lead to the withdrawal of your application. Please check the Applicant Guide for
more information.
Your Nationality (Choose from the dropdown list as shown in Appendix B)
1
Are you a United Kingdom (UK) national?
If Yes – no further action
If No – Go to question 2
YES
NO6
2
Are you a European Union (EU) national, European Economic Area (EEA)
national or Swiss national?
If Yes – Go to question 3
If No – Go to question 4
YES
NO
3
Are you a Croatian national?
If Yes – no further action. Flag as a trigger
If No – no further action
YES
NO
4
Do you have indefinite leave to remain or evidence of entitlement to enter and
work permanently in the United Kingdom?
Please note this does not include applicants currently going through the
process of applying for indefinite leave to remain.
If Yes – no further action
If No – Go to question 5
YES
NO
5
The evidence required is proof of identity (passport) and right to work (passport with appropriate visa or biometric
residence permit and correspondence from UK Border Agency)
6
If you have selected No to Q1, Q2, Q4 or Yes to Q3 above please mark with a cross those boxes in the personal
status section that define your current immigration status and complete the relevant start and expiry date.
5
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
5
Are you a non-EU/non-EEA national who is the partner, civil partner or spouse
of an EU or EEA citizen exercising a treaty right?
If Yes – no further action
If No – Go to question 6
YES
NO
6
Are you a non-EU/non-EEA national who is the partner, civil partner or spouse
of a UK citizen?
If Yes – no further action
If No – Go to question 7
YES
NO
7
Are you on a dependents visa?
If Yes – Go to Partner/Civil partner/Spouse status section
If No – Go to current immigration status section
YES
NO
Your current Immigration Status (personal status)
Select
Status
Start
Date
Tier 1 – points based system – no endorsement regarding ‘employment as a
doctor or dentist in training’
Tier 1 – points based system – with endorsement ‘no employment as a doctor or
dentist in training’
Tier 2 - points based system
Please identify your current sponsor on your biometric residence permit and
enter your Certificate of Sponsorship (COS) number.
If this is selected can a box appear of 20 characters to enter the COS
number. Text to read ‘Please enter your COS number’
Add dropdown list of sponsorship areas and lead employers including
other with free text box of Max 50 characters
Highly Skilled Migrant Programme (with start and end dates of endorsement
stamp in passport)
Tier 4 – graduate of UK medical/dental school currently in Foundation
Programme
Tier 4 – studying for a Masters/PhD
Please identify your current sponsor on your biometric residence permit and
enter your Confirmation of Acceptance for Studies (CAS) number.
If this is selected can a box appear of 20 characters to enter the CAS
number. Text to read ‘Please enter your CAS number’
Tier 5 – Medical Training Initiative
UK ancestry
Refugee in the UK
Visitor visa / PLAB visa / Business Visitor visa
6
Expiry
date
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Other immigration categories i.e. overseas government employees, innovators
etc.
If this is selected then the free text below is to be mandatory.
If other than above, please specify the immigration category (max 50 words):
Partner / civil partner / spouse status
Answers are required where your immigration status is dependent on that of your partner / civil partner
or spouse.
Dependant with endorsement – You are the partner/civil
partner/spouse of a UK/EEA national and have an endorsement
regarding ‘no employment as a doctor or dentist in training’
Dependant without endorsement – You are the partner/civil
partner/spouse of a UK/EEA national and do not have an
endorsement regarding ‘employment as a doctor or dentist in
training’
If Other than above, please specify the immigration category (max 20 words)
7
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Declaration Form: criminal records and fitness to practise
It is vitally important that you read, understand and answer the questions asked in this section by ticking each box.
Please read the notes below carefully before completing this part of the form. If you require further information, please
contact [insert details]. All enquiries will be treated in strict confidence.
We aim to promote equality of opportunity and are committed to treating all applicants for positions fairly and on merit
regardless of race, gender, marital status, religion, disability, sexual orientation or age. We undertake not to discriminate
unfairly against applicants on the basis of criminal conviction or other information declared.
The position you have applied for has been identified as a regulated activity within the terms of the Safeguarding
Vulnerable Groups Act (2006), as amended by the Protection of Freedoms Act (2012) and is eligible for an
enhanced criminal records check (Access NI in Northern Ireland) under the provisions of the Police Act 1997
(Criminal Records) Regulations (as amended). The enhanced criminal record check will, where appropriate to the role,
also include any information which may be held against the barred lists for working with children and / or adults.
Before you can be considered for appointment in a position of trust as a trainee in this position we need to be satisfied
about your character and suitability.
The position you have applied for is exempt from the Rehabilitation of Offenders Act 1974. This means that you
must declare all criminal convictions, including those that would otherwise be considered ‘spent’, under this Act.
Answering ‘yes’ to any of the questions below will not necessarily bar you from an appointment. This will depend on the
nature of the position for which you are applying and the particular circumstances.
Prior to making a final decision concerning your application, we shall discuss with you any information declared by you
that we believe may have a bearing on your suitability for the position. If we do not raise this information with you, this
is because we do not believe that it should be taken into account. In that event yYou still remain free, should you wish,
to discuss the matter with the interviewing panel. As part of assessing your application, we will only take into account
relevant criminal record and other information declared.
The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent before
processing sensitive data about you. Processing includes: obtaining, recording, holding, disclosing, destruction and
retaining information. Sensitive personal data includes any of the following information: criminal offences, criminal
convictions, criminal proceedings, disposal or sentence.
The information that you provide in this Declaration Form will be processed in accordance with the Data Protection
Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for
purposes of enquiries in relation to the prevention and detection of fraud.
This Declaration Form and any information provided relating to a positive declaration will be kept securely and in
confidence, and access to it will be restricted to designated persons within the recruiting organisation and other persons
who need to see it as part of the selection process and who are authorised to do so. If successfully appointed to a
training post, this information may be passed to designated persons in your first or lead employing organisation and any
organisations through which you rotate.
Please answer the following questions. If you answer “YES” to any of the questions, please provide full details on anby
email to [email address at LETB/ DEANERY] .Please mark the email “CONFIDENTIAL”.
If you would like to discuss what effect any previous convictions, police investigations or fitness to practise proceedings
taken or being taken either in the UK or by an overseas licensing or regulatory body might have on your application, you
may telephone: [named contact at the LETB/ DEANERY].
8
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
1
Are you currently bound over or have you ever been convicted of any
offence by a Court or Court-Martial in the United Kingdom or in any
other country?* NB You do not need to tell us about parking offences,
but other driving offences must be declared (excluding fixed penalty
notices)
YES
NO
2
Have you ever received a police caution, reprimand or final warning that
has yet to be investigated by the GMC?
YES
NO
YES
NO
YES
NO
YES
NO
Have you been charged with any offence in the United Kingdom or in
any other country that has not yet been disposed of? *
3
4
Please note: You are reminded that if you are appointed to a
training post or programme, you will have a continuing
responsibility to inform your employer(s) and the Postgraduate
Dean of any new criminal convictions, police investigations or
fitness to practise proceedings that arise in the future. You do
not need to tell us if you are charged with a parking offence but
other driving offences must be declared (excluding fixed
penalty notices).
Are you aware of any current NHS Counter Fraud and Security
Management Service (CFSMS) investigation following allegations made
against you? *
Have you been investigated by the Police, NHS CFSMS or any other
Investigatory Body resulting in a current conviction or dismissal from
your employment?*
5
Investigatory bodies include: Local Authorities, Customs and Excise,
Immigration, Passport Agency, Inland Revenue, Department of
Business, Innovation and Skills, Department of Work and Pensions,
Security Agencies, Financial Service Authority, or any successor bodies
to the above Note: This list is not exhaustive and you must declare any
investigation conducted by an Investigatory Body.
6
Have you ever been dismissed by reason of misconduct from any
employment, office or other position previously held by you? *
YES
NO
7
Have you ever been disqualified from the practice of a profession or
required to practise subject to specified limitations / conditions /
warnings following fitness to practise proceedings by a regulatory or
licensing body in the United Kingdom or in any other country? *
YES
NO
8
Are you currently the subject of any investigation or fitness to practise
proceeding by any employer, any licensing or regulatory body in the
United Kingdom or any other country? *
YES
NO
9
Are you subject to any other prohibition, limitation, or restriction that
means we are unable to consider you for the position for which you are
applying? *
YES
NO
10
Do you know of any other matters in your background which might
cause your reliability or suitability for employment to be called into
question?*
YES
NO
If you have answered "YES" to any of the questions, please provide full written details, including dates and outcomes,
and email the details to the address shown in the applicant guide. Please indicate clearly which questions you are
answering. Please mark the e-mail as “CONFIDENTIAL".
9
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
References
Reference reports are not used for scoring purposes during shortlisting or interview but will
be reviewed during the selection process and again prior to confirmation of appointment for
successful applicants. The reference process is designed to check the accuracy of your
previous employment and training history and to provide assurance of your suitability for
employment.
You must provide contact details, including e-mail addresses, of three referees who have
supervised your clinical training during the last two years of your employment or
undergraduate training. One referee must be your current or most recent consultant
or educational supervisor familiar with your clinical development. Your NHS
Employer will be required to take up references spanning the last three years of
your work and education. You will be asked to provide contacts details for these
separately in the employment history section of your application form.
If you are applying for an Academic Clinical Fellowship post, one of your referees must be
able to provide the academic reference.
You should contact your clinical referees in advance to confirm that they are willing to
provide a reference and are available and able to do so in the time period required for
selection and appointment.
Please ensure these details are correct as you will be unable to begin in post until references
are supplied and checked.
Employment or Training Post 1*
This Clinical Referee must be your present or most recent Consultant or Educational Supervisor
Specialty
Training Grade
Start Date
End Date
Name of Consultant or supervisor
Job Title
GMC/GDC Registration
What was their role in relation to you (e.g.
Consultant)?
Contact email address
Contact postal address
GMC/GDC Registration
Contact phone number
Fax number (where applicable)
Secretary’s Name (if known)
Secretary’s Contact Email Address (if known)
Secretary’s Phone Number (if known)
Employment or Training Post 2*
Specialty
Training Grade
Start Date
End Date
10
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Name of Consultant or supervisor
Job Title
GMC/GDC Registration
What was their role in relation to you
(e.g. Consultant)?
Contact email address
Contact postal address
Contact phone number
Fax number (where applicable)
Secretary’s Name (if known)
Secretary’s Contact Email Address (if
known)
Secretary’s Phone Number (if known)
Employment or Training Post 3*
Specialty
Training Grade
Start Date
End Date
Name of Consultant or supervisor
GMC/GDC Registration
What was their role in relation to you
(e.g. Consultant)?
Contact email address
Contact postal address
Contact phone number
Fax number (where applicable)
Secretary’s Name (if known)
Secretary’s Contact Email Address (if
known)
Secretary’s Phone Number (if known)
Academic Referee(The box above is not needed for ACF applications; instead the following should be
used.)
Start Date
End Date
Name of referee
Job Title
GMC/GDC Registration
What was their role in relation to you (e.g.
Consultant)?
Contact email address
Contact postal address
Contact phone number
11
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Fax number (where applicable)
Secretary’s Name (if known)
Secretary’s Contact Email Address (if known)
Secretary’s Phone Number (if known)
References
12
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Part Two
Throughout the application process anoymised following Data Protection guidelines and recruitment best practise. For
some application form questions this may not be possible e.g. publications and prizes.
I confirm that I have read the statement and understand the implications if I do not complete this application form
correctly
Programme Information
--Please Select (Specialties A-H)-Programme applied for *
--Please Select (Specialties I-O)---Please Select (Specialties P-Z)--
Entry Level*
CT/ST1, CT2/3, ST3/4, ST3+
This specialty training post/programme is not normally available to any doctor who has previously relinquished or been
released / removed from a training post/programme in this specialty.
Have you previously relinquished or been released or removed 7 from a training programme in this specialty*?
YES NO
*If yes, please provide full details for the previous release/removal from the training post/programme by
email to the address stated in the applicant guide. Please mark the email “CONFIDENTIAL”
The below key signifies the relevant information you will
need to complete, depending on the level you are applying
to.
Section 1: Evidence of Competences and Experience
Applicants to CT/ST1 Applicants Only: Achievement of Foundation Competences
In order to submit an application for a specialty training programme you need to demonstrate that you have attained
UK foundation competences or equivalent. Please ensure that you have read the guidelines regarding verification of
achievement of foundation competence at {…} before you complete this section and answer each question honestly
and accurately. Only one of the standard forms of evidence of achievement of foundation competences will be
accepted.
Your answers to the following questions will be used to determine whether you meet this requirement. If you cannot
provide one of these forms of evidence then you are not eligible to apply for a specialty training programme.
1. Are you currently in the second year of a UK affiliated Foundation Programme which finishes July
2014? Answer NO if you have already completed a UK affiliated Foundation Programme.
7
Examples might include ARCP outcome 4 or failure to progress after two or more failed RITA Es. Applications will
only be considered if there is a letter of support from the Postgraduate Dean or designated Deputy of the deanery in
which they worked. Should the Postgraduate Dean not support the application, appeal may be made to the
Recruitment Lead whose decision will be final. The Recruitment lead may be the recruitment team at the office
managing recruitment or at the deanery to whom you are making your application.
13
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
YES
Go to question 1a then question 4
NO
Go to question 2
1 a) Which Foundation School? (use drop down menu)
You meet this requirement and your application will be considered on this basis. You do not need to provide any
evidence at this stage. Any offer of a specialty training programme will be conditional upon you successfully
completing this programme and being awarded a Foundation Achievement of Competency Document (FACD 5.2) by
start of advertised programme. If appointed, evidence of your successful completion of foundation training must be
produced to your new employing trust. If you do not pass you must inform the trust / LETB/ DEANERY immediately.
2. Do you already hold a Foundation Achievement of Competency Document (FACD 5.2) from a UK
affiliated Foundation School that was completed on or after August 1st 2011?
YES
Go to question 2a then question 4
NO
Go to question 3
2 a) Which Foundation School?(use drop down menu)
You meet this requirement and your application will be considered on this basis. You MUST attach a copy of your
FACD 5.2 Certificate to your application form.
3.
Have you ever been removed or resigned from the foundation programme and do not hold an FACD
5.2
YES
Go to question 4 & 5
NO
Go to question 4 & 5
If you answer yes you will need to complete the alternative foundation competency certificate and may also be
required to evidence that you met training concerns that led to your removal or resignation for the foundation
programme. You MUST be able to show achievement of foundation competence which includes 12 months preregistration experience PLUS 12 months post registration experience and standard documentary evidence.
It is important to note that the alternative competency forms are not a direct replacement for Foundation Year 2 (e.g.
it is not expected that foundation trainees should resign after FY1 and use the alternative competency forms rather
than completing FY2.
4. Do you hold an advanced life support qualification (ALS or
equivalent qualification)
Applicants will be required to evidence completion of an ALS or
equivalent qualification by the time the start in post. If you already hold
the qualification please enter details.
YES
NO
Qualification :
Date of qualification: DD/MM/YYYY
14
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
You have answered NO to questions 1 and, 2 above. You are therefore required to show that your previous
experience meets the eligibility criteria for a specialty training programme.
Applicants who cannot demonstrate UK foundation competences via UK affiliated foundation programme must obtain,
and attach to their application, a completed and signed ‘Alternative foundation competency certificate’ from a clinical
consultant8 with whom have worked for a minimum of 3 months (whole time equivalent) since 1st August 2011
confirming that they have achieved foundation competence. The certificate can be downloaded from *****insert
link*****.
You can view the standards expected of foundation programme doctors at http://www.foundationprogramme.nhs.uk
NB: clinical attachments do not qualify for this experience]
We may ask you to provide further evidence. You are reminded that if you give false or misleading information, your
application may be disqualified.
5. Are you able to attach the Alternative foundation competency certificate to your application?*
If demonstrating your foundation competency using the alternative certificate, all candidates are required to attach
this evidence to their application prior to submission. Applications made without properly completed certification will
normally be rejected.
However, candidates with special circumstances, such as refugees, who are unable to provide a certificate at time of
application can explain their circumstances in the space provided; although they will be required to demonstrate
foundation competency before being able to take up on any future offer of a specialty training programme.
YES
Go to attachment option
NO
Go to question 6
6. Please explain why you are unable to provide an Alternative foundation competency certificate with your
application; you are reminded that applicants who cannot provide a certificate with their application will normally
be rejected unless they have special circumstances, such as being a refugee, which make the attainment of a
certificate impossible at this time.* (max 100 words)
Entry Qualification * all fields in this section
Please give details of your primary medical qualification
Primary Qualification
Qualification:
Drop-down
Date of Qualification:
Medical School / University
Medical School / University address:
Country of Primary Medical Education
Recommended contact for employment reference 9
8
Other:
If not listed
Drop-Down list
Telephone number*
A Consultant includes GPs, Clinical Directors, Medical Superintendents, and anyone on the specialty register
9
*Your future employer may need to request an employment reference from your medical school if you graduated
less than three years ago. This information will not be requested until after you have been made a conditional offer
of employment.
15
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Contact email for employment reference
Entry Qualification – Applicants to OMFS and dental specialties
Please give details of your primary dental qualification
Primary Qualification
Qualification:
Date of Qualification:
Dental School / University
Dental School / University address:
Country of Primary Dental Education
Drop-Down list
Section 2: Full Employment history – (UK/Overseas)
Please list all relevant employment (medical/dental) from current/most recent employment history detailing back to
completion of medical school. For rotational posts in core training programmes, please list each component post
separately. If you are in a rotational programme, please also list posts that you are due to rotate to up until the
advertised start date. Your future employer may need to seek references from your most recent employer and your
employment / education history for the three years leading up to your date of appointment. Although not
mandatory, it would be helpful to speed up your appointment process if you provide details of contacts who may be
able to supply this information (e.g. HR department, medical staffing department, department administrator) for all
employment undertaken during this period. It is only necessary to list contact details for posts begun in the last
three years. This information will not be requested until after you have been made a conditional offer of
employment.
Employment Gaps
You must account for any gaps in employment of longer than four weeks within three years of the advertised start date
of the post. Please note this includes:





any gap beginning from the course completion date of your primary medical qualification should this be within
the last three years; although should the period between your course completion date and your provisional
medical registration be greater than 28 days, this does not need to be declared
any expected career gaps between submission of the application form and the advertised post start date
any potential gap between the end date of your last planned post and the advertised post start date where
you do not currently know what will be your employment status – provide information about your intentions for
this period
any periods of short-term, ad hoc or locum work greater than four weeks; where this is the case, please
summarise the nature and amount of full time equivalent experience gained across any posts undertaken
during this period
any gaps where you have stepped out of programme with the expectation of returning such as to undertake
research in a formal post or to take a career break
Do you have any gaps in your employment history
of more than 4 weeks duration in the last 3 years
up to the advertised start date of the post?*
If Yes, please explain the gap (s) and give relevant
dates (max. 150 words)
Yes
No (dropdown list
Gap A
Gap B
Gap C
Add more Gaps
16
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Some person specifications require either a minimum or maximum amount of experience. To count this experience,
throughout the application processes time spent in posts / training programmes will be calculated using the formula :
number of days between the start and end dates for a particular post
X WTE
30
For periods of 12 months or more, the calculation will be, at the recruiter’s discretion, applied with a tolerance of up to
14 calendar days either way. This is to allow for such vagaries as 28 day months, fixed or staggered start dates, leap
years, etc. For periods of less than 12 months, the tolerance will be, at the recruiter’s discretion, applied with a
tolerance of up to 7 calendar days either way.
Future post 1
10
Employer name
Address
Grade
Specialty
Less Than Full
Time?
Yes
No
(dropdown list)
Start Date
Observer/Clinical attachment/unpaid post
(dropdown list)
(Dropdown list)
End Date
If LTFT what
amount?
(dropdown list)
Duration of post:
Contact for employment
reference:
(dropdown
Post
Type11
Post Title
list)
Current Level12
(dropdown
list)
Years
Email
address
Yes
No
Months
Telephone
number
Future post 2
Employer name
Address
Post Title
Post Type
Grade
(Dropdown list)
Specialty
Start Date
End Date
Contact for employment
reference:
list)
If LTFT what
Less Than Full
amount?
Time?
Current
(dropdown list)
Yes
No
Level
(dropdown list)
Observer/Clinical attachment/unpaid post
Yes
(dropdown list)
Duration of post:
Years
Email
address
(dropdown
(dropdown
list)
No
Months
Telephone
number
Current or most recent post* (all fields in this first post section)
10
11
12
Future posts should cover the period from the application date to intended start date
refer to the DH dataset paper on drop down values for Post Type
refer to the DH dataset paper on drop down values for Current Level
17
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
NHS employer
(dropdown list)
Employer name
Yes
No
Address
Post Title
Post
Type
Grade
(Dropdown list)
Specialty
Start Date
End Date
If LTFT what
Less Than Full
amount?
Time?
Current
(dropdown list) Level
Yes
No
(dropdown list)
Observer/Clinical attachment/unpaid post
(dropdown list)
Duration of post:
Contact for employment
reference:
(dropdown list)
Years
Email
address
(dropdown
list)
Yes
No
Months
Telephone
number
Previous Posts (Please list all other posts up to when you completed medical school)
Employer name
Address
Post Title
Specialty
(Dropdown list)
Start Date
End Date
Contact for employment
reference:
Post
Type
Grade
(dropdown list)
If LTFT what
Less Than Full
amount?
Time?
Current
(dropdown list) Level
Yes
No
(dropdown list)
Observer/Clinical attachment/unpaid post
(dropdown list)
Duration of post:
Years
Email
address
(dropdown
list)
Yes
Months
Telephone
number
18
No
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
PART 3
THIS SECTION AND FORWARDS WOULD BE CONSIDERED SPECIALTY SPECIFIC
AND THEREFORE WE CAN ADVISE ON BEST PRACTICE. EACH SPECIALTY/LETB/
DEANERY MAY ADAPT IT ACCORDING TO SPECIALTY AND LEVEL
Section 3.1: Career Progression – NB: Question not applicable to applicants to GP or Psychiatry
Career Progression for CT/ST1 applications 13*
Will you have completed more than 18 months (whole time equivalent) experience in this specialty or relevant
specialties14, by the start date of the post / programme to which you are applying (not including Foundation
modules)?*
Yes
No (drop down list)
Career Progression for CT/ST2 applications13*
Will you have completed at least 12 months experience (whole time equivalent) in this specialty or relevant specialties 15,
by the start date of the post / programme to which you are applying (not including Foundation modules)?*
Yes
No (drop down list)
Career Progression for CT3 applications 15*
Will you have completed at least 24 months experience (whole time equivalent) in this specialty or relevant
specialties15,by the start date of the post / programme to which you are applying (not including Foundation
modules)?*
Yes
No (drop down list)
15
Career Progression for ST3 applications *
Will you have completed at least 24 months (whole time equivalent) experience in this specialty or relevant specialties 15,
bythe start date of the post / programme to which you are applying (not including Foundation modules)?
Yes
No (drop down list)
Career Progression for ST4 applications15*
Will you have completed at least 36 months (whole time equivalent) experience in this specialty, or relevant
specialties15,by the start date of the post / programme to which you are applying (not including Foundation
modules)?
Yes
No (drop down list)
This section will be speciality specific and is only guidance as to what typical questions candidates may be
asked to complete. All application forms for each specialty and level will be adapted accordingly.
Section 3.2 : Evidence of Competences and Experience
Applicants to CT2/CT3 Applicants Only: Achievement of Core Competences
In order for you to submit an eligible application for this core training programme, you must demonstrate that you will
have achieved core / specialty competency to the level required for entry to this specialty/level by the start date of the
post / programme to which you are applying. Your answers to the following questions will be used to determine
whether you meet this requirement.
Applicants to ST3/ST4 Only: Achievement of Core Competences
13
14
15
Not applicable for GP or Psychiatry applicants
Refer to the Person Specification for more information on career progression
Not applicable for GP or Psychiatry applicants
19
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
In order for you to submit an eligible application for a higher specialty training programme, you must either
demonstrate that you are currently undertaking a UK core training programme relevant to this application and that you
will have gained all required competences by the start date of the post / programme to which you are applying or you
have achieved core competence; or that you have undertaken alternative specialty training which is relevant and
acceptable for the specialty that you are applying to. Your answers to the following questions will be used to
determine whether you meet this requirement. Please ensure that you have read any guidelines regarding verification
of achievement of core competency (in relation to the higher specialty training you are applying to) at [college / LETB/
DEANERY /specialty link] before you complete this section and answer each question honestly and accurately. Only
standard evidence of achievement of core competence will be accepted.
1. Are you currently on a UK core / specialty training programme, and expect to acquire all CT/ST1
competences and gain a satisfactory ARCP outcome for CT/ST1 by the start date of the
post/programme to which you are applying? Answer NO for posts that are not part of a designated
Core / Specialty programme associated with a UK Postgraduate Specialty School
1. Are you currently on a UK core / specialty training programme, and expect to acquire all CT/ST2
competences and gain a satisfactory ARCP outcome for CT/ST2 by the start date of the
post/programme to which you are applying? Answer NO for posts that are not part of a designated
Core / Specialty programme associated with a UK Postgraduate Specialty School
1. Are you currently on a UK core training programme, and expect to acquire all Core CT/ST1 and
CT/ST2 competences and gain a satisfactory ARCP outcome for CT/ST2 by the start date of the
post / programme to which you are applying? Answer NO for posts that are not part of a designated
Core programme associated with a UK Postgraduate LETB/ DEANERY *
1. Are you currently on a UK core training programme and expect to acquire all core competences
and a satisfactory ARCP outcome for CT/ST3 by the start date of the post / programme to which
you are applying? Answer NO for posts that are not part of a designated core programme associated with a
UK postgraduate LETB/ DEANERY *
YES
Go to question 1a then to next section
NO
Go to question 2
1a) In which LETB/ DEANERY are you currently undertaking core training? (use dropdown list)
You meet this requirement and your application will be considered on this basis. You do not need to provide any
evidence at this stage. If the information is false or misleading, your application maybe dis You meet this
requirement and your application will be considered on this basis. You do not need to provide any evidence at this
stage. If the information is false or misleading, your application maybe disqualified. Any offer of a [insert level] core
/specialty training programme will be conditional upon you achieving a satisfactory ARCP outcome for [insert level]
by the start date of the post to which you are applying. If appointed, evidence of your satisfactory ARCP outcome
for [insert level] must be produced to your new employing trust. If you do not achieve a satisfactory outcome you
must inform the trust / LETB/ DEANERY immediately.
2. Have you already achieved full core Competence evidenced by satisfactory ARCP outcomes at
CT/ST1 AND CT/ST2 levels?
YES
Go to question 2b then next section
NO
Go to question 3
If yes, in what year:
2b) In which LETB/ DEANERY did you complete your Core training and gain a satisfactory ARCP at CT2
level? (use drop down menu)
20
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
You must attach scanned copies of your ARCP for CT2or a Core Certificate of Completion (issued by the College) or
email the documents to the LETB/ DEANERY / Specialty to which you are applying before the close of the application
window. You will be required to bring the original documents if you are invited to the selection16centre.
2. Have you already achieved full core competences evidenced by satisfactory ARCP outcomes at
CT/ST1, CT/ST2 and CT/ST3 levels?
YES
Go to question 2b then next section
NO
Go to question 3
If yes, in what year:
2b) In which LETB/ DEANERY did you complete your core training and gain a satisfactory ARCP at
CT/ST3 level? (use dropdown list)
You must attach scanned copies of your ARCP for CT/ST3 (or a Core Certificate of Completion if the organisation you
are applying to issues them), or email the documents to the LETB/ DEANERY / specialty to which you are applying
before the close of the application window. You will be required to bring the original documents if you are invited to the
selection12 centre.
2. You have answered NO to question 1 above. You are therefore required to show that your previous
experience meets the eligibility criteria for this core / specialty training programme. You must have at
leastone/two years’ experience (excluding clinical attachments) in the relevant specialty posts (in the UK or abroad)
undertaken since Foundation training, or since acquisition of Foundation competences by the start date of the post to
which you are applying.
Are you able to provide one or more of the following documents to demonstrate core / specialty
competences or appropriate experience in another specialty (where applicable)? (tick all that apply)
ARCP or RITA documents showing satisfactory outcome?
YES
NO
Educational / Clinical Supervisor reports showing satisfactory outcome?
YES
NO
None of the Above
please go to Q3
3. If you are unable to provide the documentation as described above (e.g. because you are a refugee)
but you believe you have achieved Core / Specialty Competency at the required level please describe why
you believe you meet the eligibility criteria for this specialty and why you are unable to provide standard
documentation.
You should bring to the selection10 centre any documentation (e.g. other reports relating to your training, appraisals,
log book of training, reflective log, testimonials, assessments) that you believe supports your application.
[text box 100 words]
16
A selection centre is a process not a place. It involves a number of selection activities that may be delivered within
the Unit of Application.
21
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
3. You have answered NO to question 1 and 2 above. You are therefore required to show that your
previous experience meets the eligibility criteria for this core / specialty training programme. You must
have at leasttwo/three years’ experience (excluding clinical attachments) in the relevant specialty posts (in the UK or
abroad) undertaken since Foundation training, or since acquisition of Foundation competences by the start date of the
post to which you are applying.
Are you able to provide one or more of the following documents to demonstrate core / specialty
competences or appropriate experience in another specialty (where applicable)? (tick all that apply)
ARCP or RITA documents showing satisfactory outcome?
YES
NO
Educational / Clinical Supervisor reports showing satisfactory outcome?
YES
NO
Completed Certificate C (Alternative Certificate of Core Competence, relevant to the specialty)
ST3 medical specialties and some surgery specialties only
YES
NO
If you have answered yes to any of these questions you must attach / email the documents to the
LETB/ DEANERY / specialty to which you are applying before the close of the application window.
You must provide the original documents if invited to the selection 10 centre
None of the above?
Go to question 4
1. If you are unable to provide the documentation as described above (e.g.because you are a refugee)
but you believe you have achieved Core / Specialty Competency at the required level please describe
why you believe you meet the eligibility criteria for this specialty and why you are unable to provide
standard documentation.
You should bring to the selection10 centre any documentation (e.g. other reports relating to your training,
appraisals, log book of training, reflective log, testimonials, assessments) that you believe supports your
application.
[text box 100 words]
ST4 Only – Entry Requirements
Please give details of your ST4 entry level qualification relevant to your specialty
Name of Qualification:
Date of Qualification:
Do you expect to achieve all the necessary entry qualifications (exams, diplomas etc.) as specified in the person
specification by the start date of the post / programme to which you are applying?*
Yes
No (dropdown list)
Section 3.3: Evidence of Selection Criteria* all fields in this section
Please complete ALL parts of this section. If you do not have any evidence please enter ‘No evidence’. Do not leave a
section blank.
22
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
A1
a) Additional Undergraduate Degrees and Qualifications
Please list any additional completed undergraduate qualifications with dates. Include intercalated BSc/ equivalent degree
here if you have one. Do not include details of your pre-university school education/ exam results.
Complete
Qualification *
Place of Study
Grade/Honours Year
d Y/N
b Postgraduate Degrees and Qualifications
Give details ofany completed postgraduate medical qualifications/ other degrees/ diplomas/certificates (e.g. MD, MRCP
etc.). Where a qualification is partly completed please state your exam status e.g. MRCP (Part I) etc. For an MD please
state whether this is linked to your primary medical qualification or the result of an independent research thesis. Please
include here any relevant qualifications listed as desirable on the person specification.
Year
Subject/Qualification *
Place of Study
Grade/result
COMPLETED
A2 Additional achievements
Prizes, awards and other distinctions (include specialty and qualifying distinction)
Prize *
(please indicate if an undergraduate or postgraduate award)
Awarding Body
Date Awarded
(mm/yyyy)
A3 Training Courses Attended
Include in this section the most relevant training courses to this specialty that you have attended and details of courses
that you are currently undertaking. Please include any Advanced Life Support or similar courses mentioned in the Person
Specification
23
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Course Title*
Training Provider
Duration
Date Completed
Supporting Information:
The questions below require you to provide supporting information about your application for the programme.
B Achievements outside Medicine
Give details of outstanding achievements outside the field of medicine
Please note:CT 1 & CT2:Maximum 65 words CT3, ST3, ST4: Maximum 100 words
Presentations and Publications
In this section, please provide details of your most relevant publications in journals or presentations to local bodies,
regional or national societies. Please state whether the presentation was oral or a poster. Please give full citation
details of any published work (please provide PubMed link or alternative in your answer). Please give a statement about
your personal contribution to the work (e.g. first author; lead investigator).
CT/ST1/CT/ST2 - Please note: Maximum 65 words for each section
CT3/ST3/ST4Please note: Maximum 200 words for each section
C1
a) Presentations
Presentations at regional or national level.
b) Presentations
Presentations at local level
C2
a)Publications
Publications in peer review journals
b) Other Publications
Conference extracts etc.
24
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Teaching and Audit.
In this section please provide details of teaching and clinical audit experience. Please give full details including a
statement about your personal contribution to the audit work.
CT/ST1/CT/ST2 - Please note: Maximum 65 words for each section
CT3/ST3/ST4 - Please note: Maximum 200 words for each section
D Teaching Experience
What experience do you have of delivering teaching? Have you undertaken a teaching skills course or a formal
qualification in teaching?
E Clinical Audit
What experience of clinical audit do you have?
Please state clearly where & when this was undertaken and indicate specifically your role.
F Suitability for Specialty
Describe how you believe you meet the person specification for the Programme you are applying for. Include the
particular skills and attributes that make you suitable for a career in this specialty.
CT/ST1/CT/ST2/CT3 - Please note: Maximum 125 words
ST3 / ST4 - Please note: Maximum 200 words
G Commitment to Specialty - Activities and Achievements
Please provide evidence of activities and achievements which demonstrate your commitment to a career in this
specialty and/or have led to the development of skills relevant to a career in this specialty.
CT/ST1/CT/ST2/CT3 - Please note: Maximum 125 words
ST3 / ST4 - Please note: Maximum 200 words
25
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
H Management, Leadership, Teamworking and Communication skills
Please provide evidence of activities and achievements which demonstrate your skills in the above, relevant to a career
in this specialty. Please note: Maximum 200 words
Academic Recruitment Only
I. Research Skills Please give brief details of all research projects, and/or relevant research experience that you
have undertaken or are undertaking, including methods used. Indicate your level of involvement and your exact role in
the research team detailing when this took place, your time commitment, your contribution / involvement and source
of funding. If you have been awarded a higher degree as a result of research, this must be detailed additionally in the
appropriate section above. Detail your academic career plans, if applicable. Please note: Maximum 200words
Ia. Please describe in more detail one of the research projects above.
Please note: Maximum 150 words
Ib. Please say why you want this particular Academic Clinical Fellowship, indicating your medium and long –term
career goals in relation to an academic career in this specialty area. Please note: Maximum 150 words
DECLARATION (to be completed by all applicants)
Confirmation*
I confirm that:
I have met/or am expecting to meet the essential entry criteria as set out in the person specification for the
specialty and entry level to which I am applying, including, where necessary the acquisition of the relevant
competences and college memberships.
Yes
No
Declaration*
Important: The Data Protection Act 1998 requires us to advise you that we will be processing your personal data.
Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act
1998 defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs, trade union
membership, physical or mental health, sexual life, criminal offences, criminal convictions, criminal proceedings,
disposal or sentence.
The information that you provide in this Application Form will be processed in accordance with the Data Protection Act
1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes
of enquiries in relation to the prevention and detection of fraud.
Once a decision has been made concerning your appointment, [organisation] will not retain this declaration form any
longer than is necessary [see further details in ‘Guidance Notes for Applicants’]. This declaration will be kept securely
26
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
and in confidence. Access to this information will be restricted to designated persons within the trust who are
authorised to view it as a necessary part of their work.
* Declaration 1: I declare that the information I have given in support of my application, including
information supplied on this form and any attached appendices, is, to the best of my knowledge and belief
true and complete. I understand that if it is subsequently discovered that any statement is false or misleading,
or that I have withheld relevant information, particularly on criminal convictions and/or fitness to practise
and/or have breached the confidentiality guidance (2009) stipulated by the General Medical Council/General
Dental Council, my application may be disqualified or, if I have already been appointed, I may be dismissed
and that I may be reported to the General Medical Council/General Dental Council.
* Declaration 2: I declare that my answers to the questions on this form, any attached appendices and any
other application forms required by individual deaneries are my own work and are not copied or reproduced
from any other sources. I understand that if any of my answers are discovered not to be original, my
application may be disqualified.
* Declaration 3: I am aware ofparagraph 49 of Good Medical Practice which states that if I formally accept a
post I must not withdraw unless the employer has time to make other arrangements. I understand that failure
to comply with this requirement may result in a complaint being made against me to the GMC/General
Dental Council.
* Declaration 4:I understand that if I am allocated to a training opportunity, any subsequent contract of
employment will be subject to satisfactory pre-employment checks and subject to a condition that the
information provided on the application form or any related documents is correct. I also understand that preemployment checks will be carried out to review and confirm the details of my application.
* Declaration 5: I understand that employment offered in this training programme is subject to satisfactory
medical clearance which may include a medical examination and/or blood tests. I am aware that the
GMC/General Dental Council has published guidelines on fitness to practise which apply where a doctor has
contracted a disease that is potentially transmissible.
* Declaration 6: I understand that if recommended for training I will be subject to Enhanced CRB checking.
I am aware that I must inform the deanery of any new criminal convictions, police investigations or fitness to
practise proceedings that arise after the completion of this application form.
* Declaration 7:I have read and understand the Fair Privacy Notice and understand that my Personal and
Sensitive Personal Data will be processed in the manner set out in this Notice
I agree to the above declaration.
YES
Signature17
Name
Date
17
Please do not complete this signature electronically. If you are invited to interview you may be asked to sign a
paper copy at this stage.
27
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
SAMPLE EQUALITY AND DIVERSITY MONITORING
FORM FOR ALL LEVELS OF SPECIALTY
RECRUITMENT 2014
The information you enter on this Equality and Diversity monitoring form will be used for
monitoring purposes only and will not be used in assessing and/or scoring your application or
at interview stage. This information is kept confidential and accessibility is strictly limited to
individuals on a relevant basis.
Monitoring Information
Most public sector employers including health care organisations are required to collect data about an applicant. The
information is used solely for monitoring purposes to ensure that recruitment policies and procedures are applied fairly
and do not discriminate against individuals. We believe that it is good practice to employ a diverse workforce that reflects
the communities we serve.
The information you share with us will be used to monitor and evaluate how well we are doing in eliminating
discrimination and advancing equality. The NHS is committed to the principles of fairness, consistency, meritocracy and
equality of opportunity. The Equality Act 2010 requires equal treatment in access to employment as well as private and
public services, regardless of age, disability, gender re-assignment, marriage or civil partnership, maternity or pregnancy,
race, religion or belief, sex and sexual orientation.
Date of Birth*
Gender
Male
Female
I would describe my ethnic origin as:
Asian / Asian British
Mixed
Bangladeshi
Asian & White
Indian
Black African & White
Pakistani
Black Caribbean & White
Chinese
Any mixed / multiple
Other Asian
Other Ethnic Group
Undisclosed
I do not wish to disclose my ethnic
origin
White
British
Irish
Black / African / Caribbean /
Black British
African
Arab
Gypsy or Irish Traveller
Other ethnic group
Any White
Caribbean
Other Black
Please select the option which best
describes your sexuality ( please tick)
Lesbian
Gay
Bisexual
Do you live and work permanently in a gender other than that assigned at
birth?
Heterosexual
I do not wish to disclose my
sexual orientation
Yes
No
Prefer not to say
Please indicate your religion or belief ( please tick)
28
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Atheism
Islam
Buddhism
Jainism
Christianity
Judaism
Hinduism
Sikhism
Other
I do not wish to disclose my
religion/belief
For Northern Ireland applicants only
Public authorities and private sector employers registered with the Equality Commission have a legal duty to monitor
community background under the Fair Employment and Treatment (NI) Order 1998. The direct question used on the
monitoring form is:
Regardless of whether we practice religion, most of us in Northern Ireland are seen as either Catholic or Protestant. We
are therefore asking you to indicate your community background by ticking the appropriate box below:
I am a member of the Protestant
Community
I am a member of the Roman
Catholic Community
I am a member of neither the
Protestant or Roman Catholic
Community
Equality Act 2010 - Disability
The Equality Act 2010 protects people with disabilities, including people with long-term health
conditions.
Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at
least 12 months? (Please include problems related to old age)
Yes, limited a lot
Yes, limited a little
No
If you answered ‘Yes’ to the above please would you indicate if you are day-to-day activities are affected by the following:
Physical impairment
Sensory impairment
Mental health condition
Learning disability/difficulty
Long-standing illness
Other*
*If answered other, please describe below:
WHITE SPACE BOX MAX 50 WORDS
29
This form is a sample for information only. Please do not use this form for your actual
application.
Please use the forms provided by the organisation to which you are applying.
Are you married or in a civil partnership?
Yes
No
Prefer not to say
For applicants to Northern Ireland posts only
Please indicate your marital status
Cohabiting
Remarried
Divorced
Separated
Married (first marriage)
Single
Widow
Are you pregnant, on maternity leave or returning from maternity leave?
Yes
No
Prefer not to say
30