Fortis Therapy - Application Form

Application Form
Role you are applying for:
Please tell us how you heard about this vacancy:
Personal details
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail address:
example@example.com

Training and Development

Please use the space below to give details of any CPD, training or non-qualification-based development which is relevant to the role and supports your application.

Rows	Ongoing Professional Development	Study Dates	Qualification and Grade	Date Obtained
1
2
3
4
5
6
7
8
9
10

As part of your training, did you attend a placement?
If so, where was this and how many hours were completed?
Did you have personal therapy as part of this?
If so, how many sessions?
Have you had a clinical supervisor throughout your course and beyond? Who was it?

Employment History

Previous Employment: Please include any previous experience (paid or unpaid), starting with the most recent for the past 10 years.
Current or most recent employer
Name of Employer:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held:
Date Started:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Leaving Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leaving:
Salary on leaving this post:
Contact Name of Line Manager for reference:
Brief description of duties:
Previous employer
Name of Employer:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held:
Date Started:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Leaving Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Reason for leaving:
Salary on leaving this post:
Contact Name of Line Manager for reference
Brief description of duties:
Previous employer
Name of Employer:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held:
Date Started:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Leaving Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leaving
Salary on leaving this post:
Contact Name of Line Manager for reference
Brief description of duties:

Information in support of your application
What makes you 'Fortis' - how would you fit into our culture / ethos? (either 200 words in the box or send a video with your application form - 1-2 minutes - file upload below)
Convictions/ Disqualifications
To ensure the safety of our clients, you must have an enhanced DBS check completed for all positions. A criminal record will not necessarily be a bar to obtaining a position at Fortis. If a check is returned and reveals any information, this will be discussed with the applicant. The Directors will make a decision as to whether the offer of work should be withdrawn.

Rehabilitation of Offenders Act 1974 (Exceptions)(Amendment) Order 1986

We would draw your attention to the following statement:-

"Because of the nature of the 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 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986. Applicants are, therefore, not entitled to withhold information about convictions which for other purposes are 'spent' under the provisions of the Act".
Please provide details below if you have been convicted of a criminal offence or been the subject of a conditional discharge or probation order. (Past criminal proceedings are not necessarily an obstacle to taking up a post. This occurs only where the offence/s is/are deemed relevant. Any details will be discussed with you should you be the successful candidate based on your supporting statement, interview and tests).

Reasonable Adjustments/Arrangements

Please contact us if you need the application form in an alternative format.
Are you subject to any conditions relating to working in this country?
If "yes" please use the space below to tell us what these are?
If you need us to make any adaptations for a disability you have, please tell us what these are below
If appointed, when could you start? Give period of notice if applicable

References

Please give the detail of three references (please note that relaEves cannot be referees, and oneshould be a previous employer). We also require a reference from your current supervisor.
Name of First Referee and relationship to you
First Referee's Phone Number

Area CodePhone Number
First Referee's Email Address
example@example.com
First Referee's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Second Referee's and relationship to you
Second Referee's Phone Number

Area CodePhone Number
Second Referee's Email Address
example@example.com
Second Referee's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Current Supervisor
Current Supervisor's Phone Number

Area CodePhone Number
Current Supervisor's Email Address
example@example.com
Current Supervisor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is their modality?
How long have you been with this supervisor?

Declaration
Statement to be Signed by Applicant

Please complete the following declaration and sign it in the appropriate place below. If this declaration is not completed and signed, your application will not be considered. I agree that Fortis Therapy and Training can create and maintain computer and paper records of my personal data and that this will be processed and stored in accordance with the Data Protection Act 1998. I confirm that all the information given by me on this form is correct and accurate and I understand that if any of the information I have provided is later found to be false or misleading, any offer of work may be withdrawn and work can be terminated.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Please upload your qualification certificates here to support your application.

Cancelof
Is there any further information you would like to share?
Should be Empty:

Application Form

Personal details

Qualifying Questions

Areas of expertise

Preferred hours

Preferred locations

Qualifications for the role you have applied for

Training and Development

Employment History

Current or most recent employer

Previous employer

Previous employer

Information in support of your application

Convictions/ Disqualifications

Reasonable Adjustments/Arrangements

References

Declaration

Statement to be Signed by Applicant