What position are you applying for?
Please Choose One: Full-timePart-TimeDay DutyNight Duty
When are you available to start work?
Notice period (if applicable):
PERSONAL DETAILS
Title MrMrsMissMs
Last Name:
First Name
Company Use Only
Previous names/Maiden Name (if applicable) :
Sex : MaleFemaleOther
Equal Opps check:
Date of Birth:
Nationality:
Current Address:
Postcode:
Home Tel No:
Mobile No:
National Insurance Number:
E-mail Address:
Do you have a UK Passport? YesNo
Do you need permit to work in the UK? NoYes
Passport No:
If yes, please provide your work permit / visa number:
Are you lawfully resident in the UK? YesNo
Are there any restrictions on your continued residence in the UK? YesNo
Are there any restrictions on your visa? YesNo
If yes, please state your home office / port reference number here:
If yes, please detail:
Visa expiry date (if applicable):
Do you have a full driving licence? YesNo
Is it clean? YesNo
If no, please give details:
Please provide details of Next of Kin to be contacted in
Emergency :
Name of the person:
Relationship to you :
Address :
Do you have daily use of a car? YesNo
Phone Number:
BANK DETAILS
Name of Bank / Building Society:
Sort Code:
Name on Account
Account No.
(if Ltd company, give company name)
Bank Address
Office Use:
REFERENCES
Please provide details of two previous employers from whom we can obtain references. Any offer of employment is conditional on our receiving two satisfactory references. We will not approach your present employer until an offer of employment has been made and accepted.
Most Recent Employer Other Employer
Contact Name:
Job Title:
Company Name:
Address:
Telephone Number:
TRAINING / EDUCATION
Please include both educational and vocational qualifications starting with the most recent.
Dates (from - to)
Educational Institution
Qualifications Obtained
VOCATIONAL SKILLS & COMPETENCE
Please provide details of any specific skills or competence that is particularly relevant to your application (e.g. any registration , any special industry skills etc.)
EMPLOYMENT HISTORY
Please state your full employment history, starting with your most recent employer (also indicate if it was a recruitment agency), and continue backwards in time. Please continue on separate sheet if necessary.
Current Employer Company Name
Dates of Employment
Job Title
Reasons for Leaving
Salary on Leaving
Notice Period (if relevant)
Duties / Responsibilities of the Role
Company Name
DISCLOSURE AND BARRING SERVICES AND REHABILITATION OF OFFENDERS ACT (1974) DECLARATION
REHABILITATION OF OFFENDERS ACT (1975)
Because of the type of work that you have applied for, the Rehabilitation of Offenders Act (1974) (Exemptions 1975 apply) imposes a duty on people who apply for social care positions to disclose any conviction that would otherwise be considered ‘spent’.
Have you been convicted of a criminal offence? YesNo
(if yes , please provide details)
Have you been given a conditional discharge for a criminal Offence? YesNo
I UNDERSTAND THAT ANY INFORMATION I GIVE WILL BE TREATED IN THE STRICTEST CONFIDENCE. ANY INFORMATION THAT I GIVE THAT DETAILS ANY OFFENCES WILL NOT JEOPORDISE MY APPLICATION.
CRIMINAL RECORDS BUREAU DISCLOSURE
Before you can commence working as a Care Worker in the community, the Company must obtain a CRB clearance for you. You will have already completed the form and supplied documents that confirm your identity.
The Company will keep the documentation under the terms of the Data Protection Act 1998. The CRB documents will only be checked by CQC Inspectors for inspection purposes under the Care Standards Act 2000 when the Company’s records are checked.
I GIVE MY CONSENT TO THE DISCLOSURE OF THE CRB DOCUMENTATION RELATING TO MY APPLICATION ONLY IN THE CIRCUMSTANCES DESCRIBED ABOVE.
DECLARATION
I confirm that the information I have given is correct and that I have not withheld any information of which the company should be made aware. I also understand that giving any incorrect or misleading information could lead to my subsequent dismissal, or withdrawal /termination of assignment.
