Partner Application Form
Please complete this form and email it to [email protected] or alternatively, via post to:
Partners Team, The Health and Care Professions Council, Park House, 184 Kennington Park
Road, London SE11 4BU.
Part 1a
The information supplied in part 1 will not be used for selection purposes.
Partner Role applied for:
Profession & Modality
(where applicable):
Are there dates when you cannot be contacted, in relation to this application?
About you
First Name
Surname
Title
Mr/Mrs/Miss/Dr/Prof
Home postal address
Home/Mobile
telephone numbers
Work
postal address
Home
Mob
Work
telephone
number
E-mail
Please ensure that you supply a valid accessible email address as
we will communicate with you via email throughout the recruitment
process.
Your right to work
Are there any restrictions on your rights to reside/work in the United Kingdom?
Yes
If yes, please specify:
No
Your registration
Are you currently registered with the Health and Care Professions Council?
Yes
No
If yes, please state your HCPC registration number:
Disability Discrimination Act
The Disability Discrimination Act defines disability as “A physical or mental impairment
which has a substantial and long-term effect on the person’s ability to carry out normal
day-to-day activities’’
Do you consider yourself to have a disability?
Yes
No
If you answered yes to the above question, please give details:
Disabled applicants who meet the essential criteria in the person specification will be shortlisted
for interview. If you need us to make particular arrangements for completing the application form
and/or attending an interview, please contact the Partners Team (on 020 7 840 9737/776 or at the
above address) separately.
The Health and Care Professions Council is working towards equality of
opportunity in employment. To this end, the front sheet of your application, the
Equal Opportunities and Diversity Monitoring form and any other identifying
information will be detached prior to submitting applications forms for shortlisting
Part 1b – Any information declared in sections 1b – 1d will not be used for
competitive selection purposes but will be reviewed by the partners department
and a manager in the relevant user department, prior to an interview invite being
issued.
Conflicts of interest and other material information
In confidence
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 the person
concerned holds a public appointment. Information which might be relevant could include either
specific events such as those covered below or prominent activities, for example in voluntary
organisations.
The following sections ask for information which may be relevant in this context. All information
given will be treated in the strictest confidence.
Have you:
1
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
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
Any outstanding charges?
YES
NO
Been declared bankrupt in the past 10 years?
YES
NO
Been dismissed from any office or employment in the past 10 years?
YES
NO
Ever been disqualified from acting as a Company Director or in the
conduct of a company?
YES
NO
Ever been trustee of a charity?
YES
NO
2
3
4
5
6
7
8
Ever been a director, partner or manager of a company which has
gone into liquidation, receivership or administration?
YES
NO
YES
NO
9
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?
Examples should include anything that could be presented as a
conflict of interest.
If you have answered YES to any of the questions above, please give details in the
space below and continue on a separate sheet if necessary.
1
2
Of which you are, or have been, during the previous 10 years a
director or partner?
Of which you own more than 50%, whether or not you are a
director or partner?
YES
NO
YES
NO
Part 1c - Other business interests
Please note that the council has accepted proposals which reinforce the rules inspired by the
Nolan Committee on the handling of public body business and have decided to make the
appointment of new members subject to stricter conditions on members’ private interests in the
market sectors relevant to the work of the body concerned.
If you have answered YES to questions 1-2, please give details:
Name of the body and principal activities
3
4
5
Do you, or your spouse or partner, hold direct shareholdings in
market sectors linked to the work of the Health and Care Professions
Council?
Are you, or your spouse or partner, directors of commercial firms in
those market sectors?
Do you, or your spouse or partner, receive any retailer from
YES
NO
YES
NO
YES
NO
commercial firms in those market sectors?
If you have answered YES to questions 3-5, please give details:
Name of the commercial firm and principal activities
Where pecuniary interest is declared, you are asked if you are willing to forego it.
If pecuniary interest is declared are you, or your spouse or partner,
willing to forego it for the period of appointment?
YES
NO
Part 1d - Significant political activity
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.
In the last five years, have you undertaken any significant political activity? (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.
YES
NO
If YES, please give details below:
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
parts 1b, 1c, 1d.
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.
Signed:
Name in block capitals:
Date:
Part 1e
Full Name
References
Please give the names and addresses of 2 professional referees
They should be a Line Manager or someone in a position of responsibility who can comment on your
work experience. The contact details must be from a professional organisation
References should be from your:
Two most recent employers (where possible) and should
Cover your last 3 years of employment.
If your 2 referees do not cover the last 3 years of employment, please provide a 3rd professional referee.
Referees will not be contacted until a preliminary job offer has been made or without your consent.
Position held
and relationship
Organisation
Address
Postcode
Telephone
E-mail
Full Name
Position held
and relationship
Organisation
Address
Postcode
Telephone
E-mail
Data Protection
The information on this application form will be held securely, both manually and electronically
by the HCPC and will not be divulged to anyone outside the organisation. Information on
unsuccessful candidates will be held for a period of six months.
We reserve the right to verify the information you have provided and seek information from
other sources.
Declaration
Please note: You should complete all of parts 1 and 2 of the application form before
completing this section.
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 employed and any of the information I have provided is
false, my contract may be terminated.
I certify that to the best of my knowledge, the information given on this form is correct.
Signature:
Recruitment Monitoring
Where did you hear about this role?
HCPC Website
Linked In
Other External Website
Please state which site:
HCPC InFocus
GSCC Newsletter
External Publication
Please state name of publication:
Word of mouth
Other
Please state where:
Date
Part 1f - Equal Opportunities and Diversity Monitoring Form
Thank you for applying for a partner vacancy at the HCPC. The purpose of this form is to help
us monitor and improve our standards of recruitment practice.
Any information gathered for statistical analysis will be used anonymously and will not be used
to assess or score your application.
The HCPC is committed to equal opportunities and reflecting the diversity of the public. To
monitor our recruitment process we collect diversity data on all applications, which is stored
separately from the rest of your application and is not seen by any short-listing or interview
panel. It is used to produce statistics so that we can analyse the diversity profile of those
applying to the HCPC and meet the obligations of our Equality and Diversity Scheme.
Date of Birth
(dd/mm/yyyy)
Prefer not to disclose
Gender
Male
Female
Transgender
Prefer not to disclose
Prefer not to disclose
Please describe your marital status
Single
Married
Divorced
Civil Partnership
Partner
Widowed
Do you have dependent children?
Yes
No
Prefer not to disclose
If yes, please indicate number: _____________
Please select the option which best describes your sexual orientation
Lesbian
Heterosexual
Gay
Prefer not to disclose
Bisexual
Please indicate which of the following describes your ethnic group
Asian
Chinese
Bangladeshi
Chinese
Indian
Any other Chinese background
Pakistani
Mixed
Any other Asian background
Asian & White
Black
Black African & White
African
Black Caribbean & White
Caribbean
Any other mixed background
Any other Black background
Other Ethnic Group
White
Any other ethnic group
British
Undisclosed
Irish
Prefer not to disclose
Any other White background
If any other background, or any other ethnic group chosen, please specify:
................................................................................................................................................
Please indicate your religion or belief
Atheism
Islam
Sikhism
Buddhism
Jainism
Prefer not to disclose
Christianity
Judaism
Other (please specify)
Hinduism
Muslim
Do you consider yourself to have a
disability?
Yes
……………………………..
No
Prefer not to disclose
Please state the type of disability which applies to you. People may experience more than one type
of disability, in which case you may indicate more than one.
Physical
Learning Disability/Difficulty
Sensory
Long-standing illness
Mental health condition
Other (please specify if you wish)
…………………………………..……………………………………………………………….