Application Form

Application Form
Title*
First name*
Middle names
Surname*
Address*
City/town*
Postcode*
Telephone

Area CodePhone Number
Email address*
example@example.com
Rehabilitation of Offenders Act 1974 and Exception Order 1975 Because of the nature of the work for which you are applying, you must provide information about any criminal record. This includes convictions, ,cautions, reprimands and final warnings. Our power to require this lies in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 which removes the normal operation of the Act in relation to specific occupations. In the event of being employed in connection with this application, any failure to disclose such convictions could result in dismissal or disciplinary action.
Have you any unspent convictions, bid-overs, cautions, warnings or reprimands?*

YesNo
If yes, please provide details
Have you at any time received or had pending a criminal conviction, caution, warning, reprimand or bind-over?*

YesNo
If yes please provide details
Relationships Please state any relationships with any directors or current employees of Kings Medical Services and give details of who and what sort of relationship you have:
Education qualifications, result, place of study and year of achievement *
Relevant qualifications and year passed*
Membership of Professional Bodies
Professional body
Membership type / pin number / registration
Expiry date of Professional Body Registration

DayMonthYear
Date
Are you currently the subject of a fitness to practice investigation or proceeding by any professional/regulatory body in the UK or any other country? Yes No

Have you been removed from the register or have conditions been made on your registration by a fitness to practice committee or the licensing or regulatory body in the UK or in any other country? Yes No

Employment History Please provide most recent first. Use a separate sheet if necessary
Employer name*
Address*
Job title*
Main duties*
Start date*

DayMonthYear
Date
End date

DayMonthYear
Date
Reason for leaving*
Employer name
Address
Job title
Main duties
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Reason for leaving
Employer name
Address
Job title
Main duties
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Reason for leaving
Employer name
Address
Job title
Main duties
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Reason for leaving
Employer name
Address
Job title
Main duties
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Reason for leaving
Supporting Information Please provide any information you feel will support your application of employment with Kings Medical Services. You may talk about any voluntary work you have done, personal experiences, why you are interested in working with KMS or simply write a personal statement. Please continue on a separate sheet if necessary.
Please provide any information you feel will support your application of employment with Kings Medical Services. You may talk about any voluntary work you have done, personal experiences, why you are interested in working with KMS or simply write a personal statement. Please continue on a separate sheet if necessary.
Do you hold a C1 license?*

YesNo
What year did you pass your driving test?
DBS certificate Number if you hold one at an enhanced adult & child workforce level
DBS update certificate number if you hold one
Additional Information - Availability Please state your general availability for working with KMS - weekdays, evenings (from what time?), weekends, bank holidays

Please give the details of two referees, one of which must be a professional reference, the second must be able to comment on your suitability for the position
Name*

TitleForenameSurname
Address
Telephone

Area CodePhone Number
Mobile

Area CodePhone Number
Email*
example@example.com
Relationship*
KINGS MEDICAL SERVICES
Name*

TitleForenameSurname
Address
Mobile

Area CodePhone Number
Email*
example@example.com
Relationship*
I declare that all the information I have given on this application form is true and accurate, to the best of my knowledge. Please not that if you give untrue or inaccurate information, any employment contract may be invalidated.
Print name*
Date*

DayMonthYear
Date
Signature*

Clear
Should be Empty:

Application Form

KINGS MEDICAL SERVICES