PROTECT – PRIVATE PUBLIC APPOINTMENTS - APPLICATION FORM Department of Health, Social Services and Public Safety (DHSPSS) BOARD OF THE HUMAN TISSUE AUTHORITY NORTHERN IRELAND MEMBER     Applications must be made using this form - CVs will not be accepted. Please write legibly and use black ink or typescript (minimum font size 12). If completing this electronically, please do not alter the formatting/layout. This application form can be made available in other formats upon request. Please contact (028) 9052 8372 for details. Please complete all parts of this form, and return your application to the postal or e-mail address below. The closing date for this appointment opportunity is 5p.m. on 28 January 2015. Forms received after the closing time and date will not be accepted. DHSSPS Secondary Care Directorate Room 1 Annexe 1 Castle Buildings Stormont Estate Belfast BT4 3SQ For official use only Application Form Received: Official’s Name & Date: E-mail: [email protected] If e-mailing your application, to facilitate processing, please put the following as the e-mail subject line: CONFIDENTIAL - Public Appointment - HTA NI Member PROTECT – PRIVATE 1. PERSONAL DETAILS Title: Surname: Forename(s): Postal Address: Postcode: Telephone: Mobile: E-mail: National Insurance Number: 2 PROTECT – PRIVATE 2. SUITABILITY FOR APPOINTMENTSUITABILITY FOR APPOINTMENT Complete each box below using the space provided. Additional sheets will not be accepted. If typing, use minimum font size 12. (i) Corporate Governance and Scrutiny  Experience of working at or close to Board level, demonstrating application of the Principles of Corporate Governance and risk management, including the role of non-executive directors in holding executive directors to account. 3 PROTECT – PRIVATE (ii) Strategic Thinking  Experience of adding value to an organisation at a senior level by understanding its business, thinking strategically and determining the organisation’s strategic direction, and exercising sound judgment on complex and sensitive issues. 4 PROTECT – PRIVATE (iii) Financial Accountability and Management  Experience at a senior level of applying principles of financial accountability and management within an organisational setting. 5 PROTECT – PRIVATE (iv) Public Service Principles  Experience of understanding of, and commitment to, the principles of public service, and a broad understanding of the social, political and economic influences on the Health and Social Care sector. 6 PROTECT – PRIVATE Please note that the following sections 3 - 5 regarding current employment/voluntary work and public appointments play no part of the selection process. This information is used to identify any potential disqualifications and/or conflicts of interests only. 3. CURRENT EMPLOYMENT Are you currently employed? YES NO If YES, please give details below. Organisation: Start date: DD/MM/YYYY (Complete as appropriate) Position: Main Responsibilities: 4. CURRENT VOLUNTARY WORK Are you currently involved in voluntary work? YES NO If YES, please give details below. Organisation: Start date: DD/MM/YYYY (Complete as appropriate) Position: Main Responsibilities: 7 PROTECT – PRIVATE 5. CURRENT PUBLIC APPOINTMENTS Do you currently hold any public appointments? YES NO If NO, please go to Section 6. If YES, please give details below for all public appointments currently held (use additional pages as needed). Organisation: Start date: DD/MM/YYYY (Complete as appropriate) Position: Main Responsibilities: Remuneration Fees Paid: Organisation: Start date: DD/MM/YYYY (Complete as appropriate) Position: Main Responsibilities: Remuneration Fees Paid: 8 PROTECT – PRIVATE Organisation: Start date: DD/MM/YYYY (Complete as appropriate) Position: Main Responsibilities: Remuneration Fees Paid: Organisation: Start date: DD/MM/YYYY (Complete as appropriate) Position: Main Responsibilities: Remuneration Fees Paid: 9 PROTECT – PRIVATE 6. PREVIOUS RELEVANT EMPLOYMENT AND/OR VOLUNTARY WORK EXPERIENCE Please provide details of your pervious employment and/or voluntary work experience that you consider relevant to this application. Organisation: Start date: DD/MM/YYYY End date: DD/MM/YYYY Position: Main Responsibilities: Organisation: Start date: DD/MM/YYYY End date: DD/MM/YYYY Position: Main Responsibilities: 10 PROTECT – PRIVATE Organisation: Start date: DD/MM/YYYY End date: DD/MM/YYYY Position: Main Responsibilities: Organisation: Start date: DD/MM/YYYY End date: DD/MM/YYYY Position: Main Responsibilities: 11 PROTECT – PRIVATE 7. INTEGRITY/PROBITY AND CONFLICTS OF INTEREST Before you complete this section, it is important that you read section 4 of the Commissioner for Public Appointments’ Code of Practice for Ministerial Appointments to Public Bodies (2012), available at http://publicappointmentscommissioner.independent.gov.uk/wpcontent/uploads/2012/02/Code-of-Practice-20121.pdf NOTE: Conflicts of interest will be explored at interview. Are there any real, perceived or potential conflicts of interest between your circumstances and the appointment for which you have applied? YES NO If YES, please provide details below. Have you been involved in activities that could call into question your own reputation and/or damage the reputation of this organisation? YES NO If YES, please provide details below. 12 PROTECT – PRIVATE 8. DECLARATION I declare that the information I have given in support of my application is true and complete to the best of my knowledge, is an accurate reflection of my own individual experience, personal achievements and undertakings and all statements contained therein relate to me personally. I have read the candidate information pack and understand my responsibilities in relation to statutory disqualifications and public appointments. I understand that, if I am appointed and the information I have provided is incorrect, or any of the statements made in this declaration are untrue, or subsequently circumstances arise at any time before the end of my term of office which would render any such statements untrue, then my tenure of office may be terminated. In addition, I undertake that, if appointed, I must raise with the Chief Executive of the HTA any probity or conflict of interest issues that might arise during my term of appointment, and that my failure to do so could lead to my appointment being terminated. I understand and accept that the information I have provided in this form will be processed by the Department of Health, Social Services & Public Safety, in accordance with its Data Protection Registration, for the purposes of making public appointments. This may involve disclosing information to other Government Departments, the Commissioner for Public Appointments for Great Britain, and anonymously in response to Assembly/Parliamentary Questions and other enquiries. I also understand and accept that, if appointed, my name will be published in the Public Appointments Report. In addition, if appointed some of the information contained in my application will be used for a Press Release. I have read section 4 of the Commissioner for Public Appointments’ Code of Practice for Ministerial Appointments to Public Bodies (2012), and completed Section 7of this application form accordingly. Signature: Date: The closing date for this appointment opportunity is 5p.m. on 28 January 2015. Forms received after the closing time and date will not be accepted. If submitting by post, send to: DHSSPS Secondary Care Directorate Room 1 Annexe 1 Castle Buildings Stormont Estate Belfast BT4 3SQ If submitting by e-mail, please save in PDF format and submit to [email protected] with the subject line as: CONFIDENTIAL - Public Appointment - HTA NI Member 13