Application Form

Position applying for:

Title

First Name(S):

Surname:

Date of Birth

Current Address

Current Post Code

Is this your permanent address?

Yes

Telephone Number:

Mobile Number:

Email:

Are you a UK citizen?

Yes

Are you eligible to work in the UK?

Yes

Person to contact in the event of an emergency (N.O.K.):

Relationship to you:

Contact number:

Have you any relatives or friends employed here?

Yes

Education and Training:

Any technical qualifications/ Any courses attended (Certificates)

Personal Information:

Do you hold a current driving licence?

Yes

Any endorsements?

Yes

Employment History:

Please list last 3 years of employment history (If any).

Employer #1:

Employer Name:

Employer Address:

Tel. No:

Contact Name:

Start Date:

End date:

Job Title & Duties:

Reason for leaving & Gross pay:

Add new employer details

Yes

Employer #2

Employer Name:

Employer Address:

Tel. No:

Contact Name:

Start Date:

End date:

Job Title & Duties:

Reason for leaving & Gross pay:

Add new employer details

Yes

Employer #3

Employer Name:

Employer Address:

Tel. No:

Contact Name:

Start Date:

End date:

Job Title & Duties:

Reason for leaving & Gross pay:

Add new employer details

Yes

Employer #4

Employer Name:

Employer Address:

Tel. No:

Contact Name:

Start Date:

End date:

Job Title & Duties:

Reason for leaving & Gross pay:

Add new employer details

Yes

Employer #5

Employer Name:

Employer Address:

Tel. No:

Contact Name:

Start Date:

End date:

Job Title & Duties:

Reason for leaving & Gross pay:

References:

Please provide 2 reference, 1 being your present or last employer. (We will only contact your present employer if a job offer is made).

Reference #1:

Present Employer:

Position at the Company:

Address:

Post code:

Tel No:

References #2:

Name:

Position at the Company:

Address:

Post code:

Tel No:

Have you ever been convicted of a criminal offence (which is not a spent conviction within the meaning of the Rehabilitation of Offenders Act 1974)?

Yes

Health Details:

How many periods of absence have you had from work in the last 12-months, due to:

Sickness:

From (if applicable):

To (if applicable):

Other reasons:

From (if applicable):

To (if applicable):

Additional Information:

Please list any further information which you feel is appropriate for this position:

Any restrictions?

Hours required:

Medical conditions that may affect the job role:

Read & Acknowledge As Appropriate:

1. Rehabilitation of offenders Act 1974

The company is exempt from the provisions of the above act; applicants are not entitled to withold information about convictions which for other purposes are regarded as spent' in certain prescribed areas.

In the event of employment, any failure to discloe such convictions, included suspended sentences, could result in disciplinary action being taken which could result in dismissal.

Having read the above notes please complete (a) or (b) as appropriate.

(a) I certify that I have no convictions of which the proprietors should be made aware.

(b) In the light of the above notes, I wish to inform you of the following caution(s), conviction(s) and/ or reprimand(s).

2. DBS - Enhanced Disclosure

I understand that an Enhanced Disclosure will be sought in the event of a successful application

3. Health Declaration

The work within a Domiclliary care company is demanding in terms of physical requirements of all employees. The care and assistance to be given to clients due possibly to their physical handicap, involved with daily cleaning, changing beds, climbing stairs, etc.

In you own interest please do be certain in making you application for employment that you are fit for the job and that you will offer reliable attendance and be of benefit to the team.

I confirm that to the best of my knowledge I am physically and mentally fit and capable of working a full part in the care and support of the clients and the upkeep of their homes.

Application Form for Employment

Education and Training:

Personal Information:

Employment History:

Please list last 3 years of employment history (If any).

Employer #1:

Employer #2

Employer #3

Employer #4

Employer #5

References:

Reference #1:

References #2:

Health Details:

Additional Information:

Read & Acknowledge As Appropriate:

1. Rehabilitation of offenders Act 1974

2. DBS - Enhanced Disclosure

3. Health Declaration