APPLICATION FORM (NON-EXEC) - CONEXAS MICROSITES

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APPLICATION FORM

BEFORE YOU START

To complete this application, you will need:

The ID number of the role you are applying for. This can be found in the "how to apply" page of the candidate pack. Please note that applications received after the closing date will not be considered.
A covering letter explaining why the appointment interests you, how you meet the appointment criteria and what you specifically would bring to the post (no more than two pages).
A Curriculum Vitae (CV) with education and professional qualifications and full employment history. Please include daytime and evening telephone contact numbers and email addresses. The CV should include names and contact details of three referees. References will not be taken without your permission (no more than three pages).

You can upload the required documents (in pdf or Word format) at the end of this form.

All applications will be acknowledged.

What is the ID number of the role you are applying for? *

(You can find this in the "how to apply" page of the candidate pack)

Application deadline *

I acknowledge that applications submitted after the closing date will not be considered.

(The closing date can be found on the "how to apply" page of the candidate pack)

YOUR DETAILS

Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

FIT AND PROPER PERSONS DECLARATION

Are you currently in employment? *

Yes
No

(Includes self employment)

Current or most recent role *

Start date for that role *

Please state whether the following statements are true or false.

I have not been convicted of an offence by a court or court martial in the UK or in any other country. I am not currently bound over and I do not have any current unspent convictions or cautions. *

True
False

If false, please provide more information *

I have not been charged with any offence in the UK or in any other country that has not yet been disposed of. *

True
False

If false, please provide more information *

I have not been involved in tax fraud or other fraudulent behaviour including misrepresentation and/or identity theft. I am not aware of any current or previous investigations by NHS Counter Fraud or other bodies following allegations made against me in relation to matters of fraud or other financial mismanagement. *

True
False

If false, please provide more information *

I am not aware of any current or previous investigation that indicates that I have, or an organisation for which I held responsibility has, failed to adhere to recognised best practice, guidance or processes regarding care quality. *

True
False

If false, please provide more information *

I have not ever been dismissed or disciplined by reason of serious misconduct from any employment, volunteering, office or other position previously held by me. *

True
False

If false, please provide more information *

I have not been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement in the carrying out of any health and social care services and/or any other services that may require registration with the CQC. *

True
False

If false, please provide more information *

I have not been disqualified from serving as a Company Director. *

True
False

If false, please provide more information *

I have not been removed from serving as a trustee in any capacity, or been stopped from acting in a management position within any NHS or other organisation. *

True
False

If false, please provide more information *

I have not ever been disqualified, erased, removed or struck off from the practise of a profession, or required to practise subject to specified limitations following fitness to practise proceedings, by a regulatory or licensing body in the United Kingdom or in any other country. *

True
False

If false, please provide more information *

I am not: *

an undischarged bankrupt
a person who has had sequestration awarded in respect of my estate which is not discharged
subject to a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to the like effect in Scotland or Northern Ireland
a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986
a person who has made a composition arrangement with, or granted a trust deed for, creditors, and not been discharged in respect of it

If you have not checked one or more of the above, please provide more information *

I have not been sentenced, nor am I subject to being sentenced for/to imprisonment for three months or more, within the last five years *

True
False

If false, please provide more information *

I am not included on any barring list preventing me from working with children or vulnerable adults. *

True
False

If false, please provide more information *

I have not been privy to, contributed to or facilitated in any incidents regarding bullying and staff victimisation. *

True
False

If false, please provide more information *

I am not aware of any other prohibition, restriction or limitation on my appointment to the role or continuing in the role within the organisation. *

True
False

If false, please provide more information *

Checkboxes *

I agree to abide by The Nolan Principles – The Seven Principles of Public Life.

The Nolan Principles are the basis of the ethical standards expected of all employees working within the organisation.

Checkboxes *

I confirm that the information provided above is true, complete, and correct to the best of my knowledge.

DIVERSITY MONITORING

Hunter Healthcare is committed to promoting equality and diversity, and eliminating discrimination. We want to help the organisations we support to recruit a diverse range of people to their posts. Completing this part of the application form will help us do that. We know the information we are asking for is personal and sensitive in nature and you do not have to answer our questions. Doing so, however, will only take a couple of minutes and will help us to understand if we are attracting a range of different groups of people to these posts, and enable us to take action if we are not.

The information you provide will:

not be used as part of the selection process
not be seen by the interview panel
only be used for statistical purposes

We thank you in advance for your support.

Which UK region do you normally live in? *

Date of birth

Sex

Is the gender you identify with the same as your sex registered at birth?

Please type in gender identity

Sexual orientation

Please type in sexual orientation

Physical and Mental Health

Do you have any physical or mental health conditions or illnesses lasting or expected to last 12 months or more?

Yes
No
Prefer not to say

Do any of your conditions or illnesses reduce your ability to carry out day-to-day activities? *

If you need reasonable adjustments to be made to the selection process because of your physical or mental health, please let us know separately.

Ethnic and religious identity

Your ethnicity

White
Mixed or Multiple ethnic groups
Asian or Asian British
Black, Black British, Caribbean or African
Other ethnic group

Please specify:

English, Welsh, Scottish, Northern Irish or British
Irish
Gypsy or Irish Traveller
Roma
Other

Please state your other ethnicity

Please specify:

White and Black Caribbean
White and Black African
White and Asian
Other

Please state your other Mixed or Multiple ethnic group ethnicity:

Please specify:

Indian
Pakistani
Bangladeshi
Chinese
Other

Please state your other Asian or Asian British background

Please specify:

Caribbean
African
Other

Please state your other Black, Black British, Caribbean or African background

Please specify:

Arab
Other
Prefer not to say

Please state your other ethnic background

Please state your religion

None
Prefer not to say
Christian (including CofE, Catholic, Protestant and all other denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Other

Please state your other religion

I false, or

DOCUMENTS

Required attachments

Please upload the following documents

Your covering letter *

Drag & Drop Files, Choose Files to Upload

This should explain why the appointment interests you, how you meet the appointment criteria and what you specifically would bring to the post (no more than two pages).

Your CV *

Drag & Drop Files, Choose Files to Upload

This should include education and professional qualifications and full employment history. Please include daytime and evening telephone contact numbers and email addresses. The CV should include names and contact details of three referees. References will not be taken without your permission (no more than three pages).

GDPR Agreement *

I consent to having this website store my submitted information so that Hunter Healthcare Ltd. can respond to my inquiry. GDPR gives you the right to access information held about you. A subject access request should be submitted to [email protected].

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

All Rights Reserved © Copyright 2026 Hunter Healthcare Ltd

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