JOIN US Join us Contact DetailsPrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Last Name *Street Address *CityZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwePhone *Email Address *PositionPosition applied for *How did you hear about the position? *Are you applying for *Full-time positionPart-time positionDay workNight workBankDrivingDo you hold a full UK or European Economic Area (EEA) driving licence? *YesNoIf yes, has your driving licence been endorsed? *YesNoDo you have a vehicle you can use for business purposes if required? *YesNoIf yes, please explain *Full Employment HistoryPlease list below your complete and full employment history, explaining all employment gaps, starting with your most recent employer, working backwards to when you left full-time education (continue on a separate sheet if necessary). Please also attach a full CV (if possible).Full CVChoose FileNo file chosenDelete uploaded fileEmployer 1Employer's nameReference DetailsStreet AddressPhoneEmail AddressJob title and main dutiesPositionSalaryStart DateEnd DateStart Date End Date Notice periodReason for leavingEmployer 2Employer's nameReference DetailsStreet AddressPhoneEmail AddressJob title and main dutiesPositionSalaryStart DateEnd DateNotice periodReason for leavingEmployer 3Employer's nameReference DetailsStreet AddressPhoneEmail AddressJob title and main dutiesPositionSalaryStart DateEnd DateReason for leavingEducationSecondary School (name and address)Qualifications gainedStart DateEnd DateFurther EducationFurther Education e.g. college / universityQualifications gainedStart DateEnd DateQualifications and TrainingPlease give details of any professional qualifications gainedAre you undertaking any course of study at present?YesNoCharacter ReferencesPlease provide details of two people who can be contacted for a reference if you have not provided a full 5 year work history. The referee must be able to comment on your suitability and character for the post you have applied for (e.g. fellow work colleague or course tutor). Relatives and/or Partners should not act as referees. Referees will not be contacted without your consent.Reference 1Contact NameJob TitleStreet AddressPhoneEmail AddressRelationship to youNumber of years knownReference 2Contact NameJob TitleStreet AddressPhoneEmail AddressRelationship to youNumber of years knownAdditional SkillsPlease use the space below to explain why you have applied for this vacancy. You should include details of your experience, skills and personal qualities that you can bring to this role. Please continue on a separate sheet if you need to (please put your name at the top of the sheet). You will need to refer to the enclosed job description and person specification when completing this section.Please submit a copy of your resumeChoose FileNo file chosenDelete uploaded fileEligibility to work in the UK:Do you have the right to work in the UK?YesNoPlease provide details of your visa and any restrictions in the space provided below (if applicable)Other EmploymentTo allow us to monitor your working hours and comply with current legislation, please complete the following section:If you are successfully appointed to the post applied for at Vitality Healthcare, do you intend to continue with other employment?YesNoDisclosure of criminal record informationDue to 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 1974 (Exceptions) Order 1975.This means that convictions that are ‘spent’ under the terms of the Rehabilitation of Offenders Act 1974 must be disclosed and will be taken into account in deciding whether to make an appointment.Any information will be completely confidential and will be considered only in relation to this application.Please read the above carefully and then answer the following questions:Have you ever been convicted of a criminal offence?YesNoHave you ever received any official cautions, reprimands or warnings?YesNoTo your knowledge, are you currently the subject of any criminal proceedings or any police investigation?YesNoData Protection:The Vitality Healthcare Privacy Statement is available on our website (www.vitalityhealthcare.net) or a copy can be requested from the Human Resources Department. Please confirm you have accessed the Vitality Healthcare Privacy Statement and you have read, understood and agree to all the terms stated.I confirm that i have understood the private policyDateDeclaration:I declare that the information given in this application is to the best of my knowledge, complete and correct. I accept that should any statement made by me in connection with this application be found to be false, incomplete or misleading then the application shall be void and consequently, Vitality Healthcare may terminate any contract arising at any time.I confirm that i have understood the private policyDateSUBMIT