APPLICATION FORM

Please complete all sections of the application form. The form should be completed in
black ink or type. Please return the completed application form to the person
named in the ‘how to apply’ section of the Job Description.
Should you require a copy of this application form in an alternative format (for example,
braille, audio or large print), please contact us – contact details can be found on Page 7.
Post applied for:

Job reference no:

Faculty/Service/School/Hall
where vacancy exists:
Where did you see the post
advertised?

1. Personal Details
Surname/Family Name: First Name(s):

Address: Known as:

Title:

Home Tel No:

Postcode:
National Insurance Number: Work Tel No:

Nationality: Mobile No:

Do you need a work permit / certificate of Email address:

sponsorship to take up this appointment?
Yes / No
If you have answered 'no' above, and you are from outside of the EC or EEA please
state the category under which you are entitled to work in the UK (These categories
are available via the Border Agency website at http://www.bia.homeoffice.gov.uk/)

2. Clinical Staff
This section should only be completed by Clinical staff.
Professional Registration, eg GMC, GDC, NMC, (please state number, name of
professional body, expiry date and whether you have full membership or not)
Professional Body: Number:

Membership Status: Expiry Date:

2. Clinical Staff continued
Are you currently the subject of a fitness to practise investigation or proceedings by a
licensing or regulatory body, in the UK or in any other country? Yes / No

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

3. Career History
Please provide information about all relevant previous employers, starting with the most
recent, along with information about any significant gaps in your employment history.
Present/most recent employment
Name of Employer: Job Title:

Address: Current salary:

Pension Scheme:

Benefits:
Postcode:
Start date: Notice period:
End date:

Reason for leaving if no longer employed:

Previous Employment
Employer Position held Dates employed Reason for leaving
(name and full
address)

Continue on separate sheets, if required

4. Additional Supporting Information

For all posts, please use the space below to tell us about your skills and experience and
how they satisfy each of the criteria in the person specification. You might find it helpful
to use the person specification criteria as headings to structure this section. Please
continue on separate sheets, if required.

For teaching or research posts, applicants should also attach a separate sheet(s) or CV,
setting out teaching and research interests and publications (including the title, reference
and date of each publication).
5. Education and Qualifications

Starting with the most recent – (please list those relevant to the post applied for.)

Name of Institution Qualification (including subject) Grade and Date

Membership of professional societies or associations.

 6. Referees

Please provide the contact details of three referees, one of whom should be your
current or most recent employer or line manager. If you have no, or limited
previous employment, please provide referees from your school, college or
training scheme or from any voluntary/temporary work. Do not include family
members or friends.

Title: Job Title:

Name: Name of Organisation:

Telephone No: Address:

Email:
Please indicate whether a
reference may be obtained
prior to interview
Yes / No Postcode:
Relationship to referee:

Title: Job Title:

Name: Name of Organisation:

Telephone No: Address:

Email:
Please indicate whether a
reference may be obtained
prior to interview
Yes / No Postcode:
Relationship to referee:

Title: Job Title:

Name: Name of Organisation:

Telephone No: Address:

Email:
Please indicate whether a
reference may be obtained
prior to interview
Yes / No Postcode:
Relationship to referee:
7. Support for disabled applicants and staff
Support for disabled applicants:
We want to ensure that all candidates have equal access to our recruitment and selection
procedures. If you are disabled, have an impairment or long-term health condition that may
affect your ability to complete this form, or if you require any adjustments to enable you to
attend an interview or participate in the selection process, please send details, as soon as
possible, to the Recruitment Officer, our contact details are shown below. This will enable
us make any reasonable adjustments.
Support for disabled staff:
We recognise that some disabled staff members may require some practical adjustments,
once in post, to enable them to carry out their role. If, during the recruitment process, you
would like to discuss any adjustments that you might require to enable you to carry out the
role you are applying for, you are welcome to contact the Recruitment Officer to discuss
this further, our contact details are shown at the bottom of the next page. Further
information about the support available to disabled staff members is provided online
(www.equality.leeds.ac.uk/dis-serv/staff/disabled-staff/). Any information provided will not
affect your application form.

8. Other personal details

Our Guidance for Applicants overleaf provides further details on each of the following
sections and whether further information is required. It also includes the contact details of
the Recruitment Officer to whom information required in this section should be sent.

Health
Do you have a health condition that may affect your work or ability to carry out the duties
associated with the post that you are applying for? Yes / No

Retirement Policy
Please indicate if, at the time of application, you are within 9 months of our normal
retirement age. Yes / No

Criminal Convictions
Please refer to the Guidance for Applicants. Do you have any criminal convictions which
are not spent? Yes / No

If you have any spent convictions please refer to the Guidance for Applicants on when
these need to be disclosed.

Connections with the University

Are you known to any member of the appointing Faculty/School/Service/Hall? Yes / No
If Yes, please specify:

9. Declaration
I have read Section 8 and the Guidance for Applicants overleaf and have forwarded
additional information to the Recruitment Officer where applicable.
I confirm that the information provided above, and in any attachments and supplementary
information, is correct and understand that any false statement could result in my
application or appointment being terminated.
(Please type your name below if you are returning the form by email or sign if you are returning it by post).

Name / signature: Date:

Please return the completed application form to the person named in the ‘how to
apply’ section of the Job Description.
Guidance for Applicants on completion of section 8:

Health
If you have a health condition that may affect your work or ability to carry out the duties
associated with this post, please contact the Recruitment Officer to provide more
information, our contact details are shown below. Any information you provide will not
necessarily prevent you from being offered a position at the University, although it may be
necessary to refer you to the University Occupational Health Service so that further
enquiries can be made.

Retirement Policy
The University’s policy is that the normal age for retirement for staff is the 31 st July following
their 65th birthday. If, at the time of application, you are within 9 months of our normal
retirement age, you should indicate on your application form. We would not normally
employ someone who is aged within six months of this date at the time of application.
If you have answered Yes to this question, please contact our Recruitment Officer to
discuss this further as we may, in certain circumstances, be able to consider your
application further. If this has not been discussed and agreed prior to applying, the
University reserves the right not to continue with the application.

Criminal Convictions
In most cases a spent criminal record need not be declared. However, certain posts are
exempt from the Rehabilitation of Offenders Act 1974 and even a spent criminal record
must be disclosed. The Further Particulars for the post will indicate whether the post for
which you are applying for is exempt.
For all posts, please submit as a separate document full details of any unspent criminal
convictions or any criminal proceedings that are pending against you. In addition, for
exempt posts, please provide full details of any spent convictions. On this document,
please state clearly your full name the job reference number and job title of the post for
which you are applying. This document should either be sent in an envelope marked
“Private and Confidential” to the Recruitment Officer or e-mailed, our contact details are
shown below.
This information will only be considered if your application is shortlisted; if you are
unsuccessful at this stage, then the information will be destroyed. If you declare a
conviction, this will not necessarily prevent you from being offered a position at the
University.

Any general queries regarding this post and your completed application form should
be forwarded to the person named in the ‘how to apply’ section of the Job Description.

If you wish to discuss any of points covered on this page, please contact:

E-mail: [email protected] – This e-mail address is only for queries or information

relating to the points covered on this page, do not send your completed application form to
this e-mail address.

Recruitment Officer, telephone: +44 (0) 113 343 1723

Contact details for posts in the Faculty of Medicine & Health, telephone: +44 (0) 113 343
8334