Personal Details

Title

First name

Surname

Former names (if applicable)

House Name/No.

Address

Town / City

Postcode

Home telephone number

Preferred contact number

Your email

Which post/s are you applying for?
—Please choose an option—Business LeadSenior Speech & Language TherapistSpeech & Language TherapistSpeech & Language Therapy AssistantSLTA remote/CumbriaNon-executive Board MemberBusiness Support OfficerSpecialist Speech and Language Therapist in AACSpeech and Language Therapy Team LeadSenior Speech and Language Therapist in Family HubsSpecialist Speech and Language Therapist in DysphagiaSenior Speech and Language Therapist, including the Youth Justice ServiceSpeculative EnquiryStudent/VolunteerOther

Other (if applicable)

Your availability to work

How many days per week?

How many hours per week?

Annual availability?
—Please choose an option—All year roundTerm time only

Please add more detail regarding your availability if required

Salary expectation?

Where did you hear about this vacancy?
—Please choose an option—Word of mouthCommunicate websiteIndeedRCSLT jobsOther - Please specify below

Vacancy discovered 'other' (if selected)

Are you free to remain and take up employment in the UK?
—Please choose an option—YesNo

You will be required to provide appropriate documentary evidence of this at interview.

For examples of acceptable documents please see www.ukba.homeoffice.gov.uk

National Insurance No.

Licences & Certifications

DBS

Do you hold a current DBS certificate?
—Please choose an option—YesNo

Are you registered with the DBS update service?
—Please choose an option—YesNo

DBS No. (if applicable)

Driving

Do you hold a full, clean driving licence valid in the UK?
—Please choose an option—YesNo

Do you own a car or have access to one?
—Please choose an option—YesNo

You will be responsible for ensuring that you have the necessary vehicle insurance for use on business.

HCPC

Are you HCPC Registered?
—Please choose an option—YesNo

Do you have current Membership of a Professional Body / Organisation?
If so please give details

Education & Qualifications

School 11+ / Study Dates (from - to) / Qualification & grade / Date obtained

College / University Study Dates - (from-to) - Qualification & Grade - Date Obtained

Ongoing Professional Development - Study Dates(from-to) - Qualification & Grade - Date Obtained

Training & Development

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

Please include:

Relevant training courses applicable to post (including length of course/nature of training)

Employment History

Previous Employment: Please include any previous experience (paid or unpaid),
starting with the most recent first. MUST cover at least 3 years.

Name of current/most recent Employer

Notice period (weeks)?

Number of days currently worked?

Number of hours per week currently worked?

Address

Position held

Date started

Date of leaving (if applicable)

Salary

Reason for leaving or wanting to leave

Brief description of duties

Name of Employer

Address

Position held

Date started

Date of leaving (if applicable)

Salary

Reason for leaving

Brief description of duties

Name of Employer

Address

Position held

Date started

Date of leaving (if applicable)

Salary

Reason for leaving

Brief description of duties

Personal Statement

Convictions / Disqualifications

Upon offer of employment we will require a Disclosure and Barring Service
at Enhanced level and this disclosure will include details of cautions, reprimands,
or final warnings as well as convictions.

Please provide details below of any convictions which are not spent under
the terms of the Rehabilitation of Offenders Act 1974:

References

Please give the names and addresses of your two most recent employers or personal referees if no previous employment.

We reserve the right to contact any of your other previous employers within the last three years

Reference 1

Name

How is this person known to you?

Job title

Organisation

Address

Contact phone number

Email

Do you wish to be consulted before this referee is approached?
—Please choose an option—YesNo

Reference 2

Name

How is this person known to you?

Job title

Organisation

Address

Contact phone number

Email

Do you wish to be consulted before this referee is approached?
—Please choose an option—YesNo

Declaration

Please complete the following declaration and sign it in the appropriate place below.
If this declaration is not completed, your application will not be considered.

I agree that Communicate SLT CIC 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 agree to the above

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 employment may be withdrawn or employment terminated.
I agree to the above

I confirm that I am not disqualified to work with children, on the Barred Lists of the
Independent Safeguarding Authority or subject to sanctions imposed by a regulatory Authority and
that I have no convictions, cautions or bind-overs, including those regarded as 'spent'
I agree to the above

If I have any criminal records I will be required to provide details

I agree to the above