Confidential Council member application form

Please complete and return to: Bolaji Banjo, Appointments Project manager

The Health and Care Professions Council Park House, 184 Kennington Park Road,

London SE11 4BU appointments@hcpc-uk.org

Position applied for: HCPC Council member Date of application:

Your personal details

Title (Mr,Ms,Dr,etc.): Surname:

Forenames:

Home address:

Business address:

Home Telephone no: Mobile phone no: Email:

Work Telephone no: Fax: Email:

Please indicate whether you would prefer to be contacted using your home or work contact details:

National Insurance Number:

Do you need a work permit for the UK?

How did you hear about this position?

In order that appropriate adjustments can be made, please can you tell us if you have a health problem or disability that you consider to be relevant to your application?

If yes, please specify:

*Disabled people who meet the criteria in the person specification will be shortlisted for interview. Please contact Bolaji Banjo (020 7840 9785 or at the above address) separately if you need us to make particular arrangements for completing the application form, attending an interview, or any reasonable adjustments that would need to be made to the job or working environment if your application is successful.

The Health and Care Professions Council is working towards equality of opportunity in employment and to this end, the personal data in your application form above, and the Equal Opportunity & Diversity Monitoring Form, will be detached prior to submitting application forms for shortlisting.

Current status

Profession: For Registrant Council member positions only

HCPC registration number: For Registrant Council member positions only Please refer to the Eligibility section of the information pack for further details.

Employment

Occupation and Employer:

Academic, professional or vocational qualifications:

Career history (most recent first)

Dates

Employer and position held

Duties and reason for leaving

Current and previous public appointments Please specify the nature and term of office of any current or previous public appointments held

Supporting statement

Please use this space, and a continuation sheet if necessary

Explain why you are applying for the role Describe how your experience, skills, knowledge and education and training

meet the person specification and are relevant to the role brief. Provide any other information that is relevant to your application.

Additional information

Please give any additional information that may be relevant for this application, such as the dates of forthcoming holidays when you cannot be contacted.

References

Please give the names and addresses of two people willing to support your application. Referees will not be contacted without your consent.

Name

Position

Name and address of organisation

Telephone no

How do you know this referee?

Name

Position

Name and address of organisation

Telephone no

How do you know this referee?

Data protection The information on this application form will be held securely, both hard copy and on HCPC’s computer database, and will only be shared with the Professional Standards Authority and the Privy Council for the purposes of the Appointments process. Information on successful candidates may be held indefinitely. Information on unsuccessful candidates will be held for up to two years in accordance with the HCPC’s information management policy. We reserve the right to verify the information you have provided and seek information from other sources. The information on the equal opportunities monitoring form will only be used for monitoring our equal opportunities policy. Any information required for statistical analysis will be used anonymously.

Declaration I declare that all the information given on this form is, to the best of my knowledge, complete and correct. I understand that if I am appointed and any of the information I have provided is false, my appointment may be terminated. Signature …………………………………….. Print …………………………………….. Date ……………………………………..

Conflicts of interest and other material information

Eligibility for membership of the Council is determined by the Health and Care Professions Council (Constitution) (Amendment) Order. For further information please refer to the information pack, and the HCPC website. A person appointed to a public body could find that matters or incidents which previously attracted no attention could become matters of legitimate public interest when holding a public appointment. The following sections ask for information which may be relevant in this context.

Have you: 1.

(a) ever been convicted of any criminal offences or accepted a caution in the UK (other than minor motoring offences) which are not spent in accordance with the Rehabilitation of Offenders Act 1974, or of any offences elsewhere which if committed in England and Wales would be criminal offences? yes no

(b)

ever been the subject of disqualification from the practice of a profession in the UK or elsewhere which remains in force; or are you the subject of any proceedings which could lead to such a disqualification? yes no

(c)

any charges outstanding? yes no

(d)

become bankrupt over the past 10 years? yes no

(e)

been dismissed from any office or employment over the past 10 years? yes no

(f)

ever been disqualified from acting as a Company Director or in the conduct of a company? yes no

(g)

ever been a director, partner or manager of a company which has gone into liquidation, receivership or administration? yes no

(h)

any other facts to declare which you feel could be raised publicly in the future relating to your suitability to hold the appointment for which you are being considered? yes no

2. If you have answered yes to a question in section 1, please provide details below, continuing on a separate sheet if necessary.

3. Do you have a relationship, either personal or professional,

with any member of the assessment and selection panel? If yes please outline: yes no

4. Do you have a relationship, either personal or professional,

with any member of the Health and Care Professions Council or Executive? If yes please outline: yes no

5.

Please provide details of membership of or position of general control or management of (current memberships or those held in the last two years):

(a)

body exercising functions of a public nature:

(b)

body directed to charitable purposes:

(c)

body whose principal purposes includes the influence of public opinion or policy (including any political party or trade union*):

6.

Directorships in public and private companies including non-executive directorships:

7.

Details of any shareholdings which gives you a majority or controlling interest in any undertaking:

8. Description of any contracts for goods, services or works made between the HCPC and you or a firm in which you are a partner, or a company of which you are remunerated as a director :

9. Please provide details of any significant political activity undertaken in the last five years. This should include activities that are a matter of public record i.e. office holding in, public speaking in support of, or candidate on behalf of, any political party (or affiliated body) which fields candidates at local or general elections in any part of the UK or in elections to the European Parliament*.

*The Nolan Committee on standards in Public Life recommended that all candidates should declare any significant political activity. Political activity information will be used for monitoring purposes only and will not determine your suitability for appointment. If your application is successful, this information will become part of the public record.

Declaration

I undertake to advise the Council of any other information relevant to an assessment of suitability as a public appointee and to report and significant future change to the information I have provided on this form.

I certify that if appointed to a position at HCPC, I will inform the Council of any change of circumstance which would result in a YES answer having to be given to any of the questions in Section 1.

I confirm that the information given on this form is complete and true, to the best of my knowledge. I understand that if I am appointed and the information I have provided is subsequently found to be untrue, then my tenure of office may be terminated.

Signature …………………………………………………………………………………… Print …………………………………………….. Date..................................................

Equal opportunity & diversity monitoring form The HCPC is working towards equality of opportunity in employment. This information will be used to statistically monitor the diversity of our workforce, and of applicants to HCPC positions. You are not obligated to complete this form, though we hope you will do so. It will be detached from your application and will not be held with or connected to your personal file.

1. Gender male female Prefer not to say

2. Age range up to 18 36-45 56-60

19-25 46-55 over 60

26-35 Prefer not to say

3. Marital status single married living with partner

widowed divorced Prefer not to say 4. Do you have a

disability? no yes Prefer not to say

5. Which ethnicity do you consider yourself? Please choose one section A-F, then tick the appropriate box or enter your cultural background:

A White

British Scottish

English Northern Irish

Welsh Any other White background:

B Mixed

White and Black Caribbean White and Asian

White and Black African Any other mixed background:

C Asian, Asian British

Indian Bangladeshi

Pakistani Any other Asian background:

D Black, Black British

Caribbean Any other black background:

African

E Chinese, Chinese British

Chinese Any other Chinese background:

F Any other background

Any other background:

G Prefer not to say

6. Sexual Orientation Bisexual Gay woman Other

Gay Man Heterosexual Prefer not to say

7. Religion and Belief Christian Hindu Other

Muslim Jewish None

Buddhist Sikh Prefer not to say