THACKRAY MEDICAL MUSEUMAPPLICATION FORM

Personal details

Title Full name

Home address

Postcode Email

Tel Mobile

FURTHER AND HIGHER EDUCATION

Secondary Education

From ToEducational

establishment(s)Qualifications obtained

(inc main subjects) Grade

Further and Higher EducationPlease provide details of your post-secondary education qualifications, e.g. diplomas, degrees, etc.

From ToEducational

establishment(s)Qualifications obtained

(inc. main subjects) Grade

Job Application

Professional qualifications and / or membership of professional bodies

Professional body Status (ie Member, Fellow, etc)or qualification obtained

Other relevant training

Brief description/course title Date (from-to) Qualification(s) obtained

Employment history (starting with current or most recent post)Please copy or expand this page for additional employment information, if required

Employer’s name

Address (inc post code)

Type of businessJob title Salary £

Employed from Employed toBrief outline of duties:

Job Application

Previous employment

Employer’s nameFull address

Type of business

Job title

Employed from Employed to

Brief outline of duties and reason for leaving:

Employer’s NameFull Address

Type of Business

Job Title

Employed from Employed to

Brief outline of duties and reason for leaving:

Job Application

SUPPORTING STATEMENT

Please state briefly why you are applying for this post, and how your achievements, experience, skills, personal qualities, etc are relevant to the post by relating them to the job description. This statement should be no more than 2 sides of A4 size paper.

Job Application

ReferencesPlease provide names, positions and full contact details (including e-mail) of at least two referees who should not be related to you. One should be your present or most recent employer.

Referee 1 (current/most recent employer) Referee 2

Contact details

Relationship to yourself*

* eg line manager, colleague, ex-manager, etc

May we contact your present employer if you are short-listed?(please tick)

Yes No

The Thackray Museum wishes to encourage suitably qualified disabled people to apply for jobs. Do you consider yourself to have a disability? (please tick)

Yes No

If yes, please give details:

Please list any assistance/adjustments you believe may be required to attend interview and/or carry out the duties of the job:

DeclarationI confirm that the above information is correct to the best of my knowledge. I agree that the information given in my application may be used for purposes registered under the Data Protection Act 1998 and I consent to the information being stored on manual and computerised files for relevant employment related purposes.

Signed* Date

*If applying by email, you may be required to sign your application at a later stage.

All employment is subject to the receipt of references satisfactory to Thackray Museum.Please return this form by the stated closing date, by post or e-mail to:

Nat Edwards, Thackray Medical Museum, Beckett Street, Leeds, West Yorkshire LS9 7LNnat.edwards@thackraymuseum.org

The Thackray Medical Museum welcomes applications from all sections of the community.