Speciality Doctor

Personal Information

Please note this form cannot be saved as a draft. If you wish to save a draft of your answers before submitting your application, we would recommend using another documents such as Word.

All questions marked with * are mandatory and must be filled before submitting your application.

Title *

First name *

Surname *

Other names

Mobile number *

Email address *

Address *

Town *

County *

Postcode *

Country *

Please confirm if you have the legal right to work in the United Kingdom? *

Please provide your professional registration number and expiry date if applicable

Do you have any family members, relatives, or close personal relationships with anyone currently employed at Martin House? *

If yes, please provide the name(s) and the nature of the relationship.

Have you or any of your family members used Martin House's services? *

Training and Qualifications

Please provide details of your professional training and qualifications. Please include full name of the course/degree and completion dates.

Training & Qualifications

Work History

Please complete details of your current and previous employment as requested below:

Please list the employment in chronological order, most recent first.
Please include your full work history from the last 6 years if applicable.

To meet CQC requirements, if you are applying for a role in our care teams, please include your full employment history since you left school/ college and include any employment gaps.

Job title

Employment start date

Is this your current employment, if not please complete the next question

Employment end date

Name of employer

Reason for leaving

Main duties and responsibilities

Job title

Employment start date

Employment end date

Name of employer

Reason for leaving

Main duties and responsibilities

Job title

Employment start date

Employment end date

Name of employer

Reason for leaving

Main duties and responsibilities

Job title

Employment start date

Employment end date

Name of employer

Reason for leaving

Main duties and responsibilities

Please use this field to add additional employment history

Please add details of any gaps in your employment history

Personal Statement

Using the Job Description for this role as a guide, please outline how your skills, abilities and values meet the key requirements and responsibilities of the role. Please use examples in your application. We recommend no more than 1000 words.

Personal statement *

The Rehabilitation of Offenders Act 1974

By virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975, the provisions of Section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such a kind as to enable the holder to have access of persons in receipt of such services in the course of his/her normal duties.

If the role you are applying for does NOT involve working with children or vulnerable adults, please complete Section A. If the role you are applying for involves working with children or vulnerable adults, please complete Section B.

Section A

Have you ever been convicted of a criminal offence in the UK or any other country? (You do not need to disclose convictions deemed as ‘Spent’ under the Rehabilitation of Offenders legislation)

If YES, please give details:

Section B

If your role does require an enhanced DBS check, spent convictions must be disclosed and will be taken into account in deciding whether to make an appointment. Further details can be found at www.gov.uk/government/publications/dbs-filtering-guidance/dbs-filtering-guide. The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013 and 2020) provides that when applying for certain jobs and activities, certain convictions and cautions are considered ‘protected’. This means that they do not need to be disclosed to employers, and if they are disclosed, employers cannot take them into account. If you require additional information around the disclosure of convictions, we recommend you take independent advice; resources can be found at www.nacro.org.uk.

It is a criminal offence for people barred from working in regulated activity to apply for roles that require them to work unsupervised with that particular group e.g. vulnerable adults, children or both.

Please note if you reply 'Yes' to any of the following questions, you will be asked to provide further details should your application is shortlisted for an interview.

Have you ever been convicted of a criminal offence in the UK or any other country?

Are you the subject of any police investigation or prosecution?

Are you, or have you ever been, the subject of any investigation or proceeding by any Professional Regulatory Body or any other organisation?

Have you ever been disqualified from practising your profession, or been the subject of any limitations to your practice following investigation by a regulatory body in the UK or any other country?

Declaration and Consent

I am fit to carry out the duties of the position applied for. *

By submitting my application, I confirm that the information given on this form is true and complete to the best of my knowledge. I agree that any deliberately false or misleading information will be sufficient cause to reject my application, withdraw any offer made, or, if employed, to terminate my employment with immediate effect.