ࡱ> !` bjbj\\ >>fffffff$VVVVWfXXXXXYYY[f]f]f]f]f]f]f$hhjff\YY\\fffXXf]]]\ fXfX[f]\[f]]o`ff`XX P4*{V\"``df0f`,k\6k`kf`<Y!Zr]Z\ZYYYff] YYYf\\\\4:d:ffffff ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS - CEMACH APPLICATION FORM Please complete this application form in black ink or type for ease of copying. If you have any difficulties in completing this form please contact us on 020 7486 1191. Whilst a CV may support your application you are asked to complete this form in full. Position applied for:Closing date:Where did you see this post advertised:Part A: Personal InformationTitle:Surname:Forename(s):Home address: Correspondence address (if different):Home telephone: Mobile: Work telephone: May we contact you at work: Yes / No Email: May we contact you by email: Yes / NoDo you have a valid work permit for employment in the United Kingdom? Yes ( No (Notice period:Part B: Education and TrainingCollege / UniversityFromToCourses and Results Secondary EducationFromToExaminations and Results  Professional training / qualifications, with dates and levels attained: Other training / courses attended relevant to this post: Part C: Current EmploymentPresent or most recent employer, nature of business and addressFromToPosition held and nature of dutiesReason for leaving Current SalaryPart D: Employment HistoryDates Name and address of employerPosition heldSummary of main dutiesReason for Leaving  Please use additional sheet if required Part E: Supporting StatementPlease outline the skills and experience you have gained through paid employment, other work activities and interests which are relevant to your application for this job Part F: GeneralPlease give details of your interests / hobbies / sports Part G: Health DeclarationAre you in good health? Yes ( No ( Have you had any serious recurring illness, injury or result of an accident in the last five years? Yes ( No ( If yes please specify ______________________________________________________ Number of days off for ill health in the past two years ___________________________Part H: Additional InformationCriminal Convictions: Please note that the provisions of the Rehabilitation of Offenders Act 1974, as amended, apply. Please enclose details of conviction(s) of a criminal offence that is not spent under the Rehabilitation of Offenders Act in a sealed envelope attached to your completed application form marked for the attention of the Head of Personnel.If offered this position will you also be working in a paid capacity elsewhere? Yes ( No (Part I: ReferencesPlease give the name and current addresses of two referees (other than relatives or friends) with knowledge of you and your work. One should be your current or most recent employer. Present or most recent employerName and title: Position held: Telephone: Fax:Address: Postcode: Email:Other refereeName and title: Position held: Telephone: Fax:Address: Postcode: Email:May we approach your present employer for a reference before interview?( Yes ( NoPart J: DeclarationYou are required to sign the declaration below certifying that all information provided is accurate. Providing incorrect information or deliberately concealing relevant facts may result in disqualification from the selection process or, where discovery is made after an appointment, in summary dismissal. I declare the information on this form is correct and I have omitted nothing that, to the best of my knowledge, might affect this application. Signature Date ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS - CEMACH EQUAL OPPORTUNITIES MONITORING FORM The College is committed to promote equal opportunities in employment and prohibiting unlawful discrimination on the grounds of sex, marital status, race, colour, national or ethnic origin, disability, sexual orientation and religion. In order to ensure that these policies are being followed all applicants are asked to provide the following information, which will be treated in the strictest confidence and will not form part of the selection process. Information given is for monitoring purposes only and is subject to the provisions of the Data Protection Act 1998. Application for (job title):Where did you see this job advertised?NameMale / FemaleAgeMarital Status What is your Nationality?Ethnic Origin (please tick the box which most closely relates to you)White BritishIrishOther Black AfricanCaribbeanOther Chinese ChineseMixed White and Black AfricanWhite and Black AsianWhite and Black Caribbean Asian BangladeshiIndianPakistani Other Ethnic Background (please specify):Disability Do you consider yourself disabled? 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