APPLICATION FORM – Profad Care Agency

PERSONAL INFORMATION

Branch Name Preferred Title First Name Surname Previous Surname Address Postcode Date you moved to this address Landline Number Mobile Number National Insurance No. Date of Birth Email Address Place of Birth (Town / Country)

Do you hold a clean driving licence?

Yes No

Do you have a car?

Yes No

Are you eligible to work in the UK?

Yes No

Can you work alone with male service users?

Yes No

Pet allergies or fear of pets?

Yes No

When can you start? Have you planned any holiday? If yes, please put the dates

Please complete all fields. If a field does not apply, enter N/A.

NEXT OF KIN

(A family member or friend we can contact in an emergency)

Name

Relationship

Address

Telephone

PRESENT OR LAST EMPLOYMENT

(Use present or last education if you have no employment history) If you do not wish us to send a reference before interview, tick this box

Job / Course Title

Employer / School Name

Referee Name

Email Address

Address

Post Code

Telephone

Start Date

End Date

Reason for Leaving

PREVIOUS EMPLOYMENT HISTORY

(Last five years – add up to 3)

Employer Name, Address & Telephone

Title of Post Held

Name of Immediate Supervisor

Main Duties / Responsibilities

Salary

Part Time /Full Time

From

To

Reason for Leaving

Please complete all fields. Use N/A where not applicable.

EDUCATION AND EMPLOYMENT GAP

(Please explain in detail the gaps in your education and employment history if any)

From

To

Reason for the Gap

EDUCATION / TRAINING HISTORY

School / College / University

Course Title

Qualification Received

From

To

Part Time or Full Time Qualification Received

RELEVANT CARE TRAINING

Course Title / Subject

Year

Length

Qualification Received

Organising Body Name & Address

LANGUAGES

DO YOU SPEAK ANY OTHER LANGUAGES BESIDES ENGLISH? IF YES, PLEASE STATE:

Language

Please complete all fields. If a field does not apply, enter N/A.

REFERENCES

Please provide names and addresses of two (2) people we can contact for reference, including one from your last employer or college. Referees should not be a relative or friend. Your referees should know you for at least six (6) months. Please write in capital letters.

WORK RELATED REFERENCES

1ST REFEREE – WORK RELATED

Contact Name (MR / MS)

His / Her Position

Organisation Address

Postcode

Daytime Telephone

Fax No

Email

Your Position

Dates Worked – From

Dates Worked – To

CHARACTER REFERENCES

1ST REFEREE – CHARACTER

Contact Name (MR / MS)

His / Her Position

Organisation Address

Postcode

Daytime Telephone

Fax No

Email

Your Position

Dates Worked – From

Dates Worked – To

ADDRESSES (Please list your addresses in the past 5 years)

Address 1

Full Address

Date From

Date To

Please complete all fields. If a field does not apply, enter N/A.

REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the work involved, the post for which you are applying is exempt from section 4(2) of the Rehabilitation of Offenders Act 1974. You are not entitled to withhold information relating to any conviction you may have had.

Have You Committed Any Criminal Offence?

Yes No

Do You Have Any Conviction?

Yes No

Have You Been Given Any Warning Before?

Yes No

If you answered YES to any of the above questions, please give details below.

DECLARATION

Declare any investigation, enquiry, or reason you may be considered unsuitable to work with children or vulnerable adults. If none, write N/A.

ASYLUM & IMMIGRATION ACT 1996

Please tick the document you will provide to confirm your eligibility to work in the UK:

A birth certificate issued in the United Kingdom or in the Republic of Ireland or a certificate of registration or Naturalisation as a British citizen.
A passport which described the holder as a British citizen or as having a right abode in the United Kingdom or a passport or other travel document endorsed to show that the holder has indefinite leave to remain in the United Kingdom and is not precluded from taking the employment in question.
EEA A passport or an identity card issued by a state which is a party of the European Economic Area agreement and which describes the holder as a national of a state which is a party to that agreement
A letter issued by the home office or the department of education and employment indicating that the person named in the letter has permission to take the employment in question.

PRIVACY NOTICE

We process personal data relating to those who apply for job vacancies with us or who send speculative job applications to us. We do this for employment purposes, to assist us in the selection of candidates for employment, and to assist in the running of the business. The personal data may include identifiers such as name, date of birth, personal characteristics such as gender, qualifications and previous employment history.
We will not share any identifiable information about you with third parties without your consent unless the law allows or requires us to do so. The personal data provided during an application process will be retained for a period of at least six months or, if required by law, for as long as is required.
This privacy notice does not form part of an employment offer or contract between us. If we make an employment offer to you, we will provide further information about our handling of your personal information in an employment context separately. If you would like to find out more about our data retention policy and how we use your personal data, you want to see a copy of the information about you that we hold or have any questions or issues regarding data protection, please email us with the Subject “Data Protection Request”.

I confirm that I have read and understood all the questions and statements on this form. The answers I have furnished are true and correct to the best of my knowledge and belief. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references and process my personal data according to the GDPR regulation.

Please Print Your Name Signed Date

CARE EXPERIENCE

Name

Position

Experience

Use of Equipment / Manual Handling Tasks

DIVERSITY MONITORING

Name

Position

Please Tick

Disability

Do you consider yourself to have a disability as defined by the Disability Discrimination Act 1995? e.g. a physical and/or mental impairment, which has a substantial and long-term adverse effect on your ability to undertake day to day activities.

Yes
No

If yes, do you need any help during the interview? Yes
No

Are there any reasonable adjustments that would assist you in attending an interview?

What is your ethnic group? Please only tick ONE of the four groups below

Our ethnic background describes how we think of ourselves. Ethnic background is not the same as nationality or country of birth.

1) White
White British
White Irish

Any other White background – please specify.

Any other Asian background – please specify.

3) Mixed
White and Black Caribbean
White and Black African
White and Asian

Any other Mixed background – please specify.

4) Black or Black British
Black British
Caribbean
African

Any other Black background – please specify.

5) Religion
Christian
Muslim
Buddhist
Hindu

Any other Religion – please specify.

Nationality

Where did you see this post advertised?

Please complete all fields. If a field does not apply, enter N/A.

QUESTIONNAIRE

Name

Date

Do you have history of

Please specify (if YES to any above)

Have you been vaccinated against

If yes, please enter the date of vaccination.

Please complete all fields. If a field does not apply, enter N/A.

PERSONAL INFORMATION

NEXT OF KIN

PRESENT OR LAST EMPLOYMENT

PREVIOUS EMPLOYMENT HISTORY

EDUCATION AND EMPLOYMENT GAP

EDUCATION / TRAINING HISTORY

RELEVANT CARE TRAINING

LANGUAGES

REFERENCES

WORK RELATED REFERENCES

1ST REFEREE – WORK RELATED

CHARACTER REFERENCES

1ST REFEREE – CHARACTER

ADDRESSES (Please list your addresses in the past 5 years)

Address 1

REHABILITATION OF OFFENDERS ACT 1974

DECLARATION

ASYLUM & IMMIGRATION ACT 1996

PRIVACY NOTICE

CARE EXPERIENCE

Experience

Use of Equipment / Manual Handling Tasks

DIVERSITY MONITORING

What is your ethnic group? Please only tick ONE of the four groups below

QUESTIONNAIRE

Do you have history of

Have you been vaccinated against

Application Submitted Successfully