Contact Form DemoPosition Applying forTitleFirst Name (S)SurnameDate of BirthCurrent AddressCurrent Post CodeIs this your permanent address?- Select -YesNoTelephone NumberMobile NumberEmailAre you a UK citizen? Yes NoAre you eligible to work in the UK? Yes NoPerson to contact in the event of an emergency (N.O.K.)Relationship to youContact numberHave you any relatives or friends employed here? Yes NoEducation and TrainingAny technical qualifications/ Any courses attended (Certificates)Personal InformationDo you hold a current driving licence? Yes NoAny endorsements? Yes NoEmployment History List of last 3 years of employment history (If any) Employer #1Employer NameEmployer AddressTel. NoContact NameStart DateEnd DateJob Title & DutiesReason for leaving & Gross payAdd another Employee details? Yes NoEmployer #2Employer NameEmployer AddressTel. NoContact NameStart DateEnd DateJob Title & DutiesReason for leaving & Gross payAdd another Employee details? Yes NoEmployer #3Employer NameEmployer AddressTel. NoContact NameStart DateEnd DateJob Title & DutiesReason for leaving & Gross payAdd another Employee details? Yes NoEmployer #4Employer NameEmployer AddressTel. NoContact NameStart DateEnd DateJob Title & DutiesReason for leaving & Gross payAdd another Employee details? Yes NoEmployer #5Employer NameEmployer AddressTel. NoContact NameStart DateEnd DateJob Title & DutiesReason for leaving & Gross payReferences 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 #1Present EmployerPosition at the CompanyAddressPost codeTel NoEmailReference #2Present EmployerPosition at the CompanyAddressPost codeTel NoEmailHave 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 NoHealth DetailsHow 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 InformationPlease 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 Appropriate1. Rehabilitation of offenders Act 1974The 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 application3. 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 homesSubmit Form