PERSONAL INFORMATION
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)
When can you start?
NEXT OF KIN (A Member of Family or Friend We Can Contact In The Case Of Emergency)
Name
Relationship
Address
Telephone
PRESENT OR LAST EMPLOYMENT (PLEASE USE PRESENT OR LAST EDUCATION IF YOU HAVE NO EMPLOYMENT HISTORY)
Job/ Course Title
Employer/ School Name
Referee Name
Email Address
Address
Post Code
Telephone
Start Date
End Date
Employment only
Reason for Leaving
PREVIOUS EMPLOYMENT HISTORY (We need your last five years history).
Employers’ Name, Address & Telephone No.
Title of Post Held
Immediate Supervisor
Main duties, responsibilities and achievements
Salary
Dates Employed
Month/Year
From
To
Part Time/ Full Time
Part Reason for Leaving/ Full Time
EDUCATION AND EMPLOYMENT GAP
(Please explain in detail the gaps in your education and employment history if any)
Date
From
To
Reason for the Gap
EDUCATION / TRAINING HISTORY
Name of School, College or University
Course Title
Dates Studied
Month/Year
From
To
Part time or Full Time
Qualification Received
RELEVANT CARE TRAINING
Course Title/ subject
Year
Length
Organising Body name & address
Qualification Received
LANGUAGES
DO YOU SPEAK ANY OTHER LANGUAGES BESIDES ENGLISH? IF YES PLEASE STATE:
1
2
REFERENCE
1ST REFEREE WORK RELATED
CONTACT NAME: MR/MS
HIS/HER POSITION
ORGANISATION
ADDRESS
POSTCODE
DAYTIME TELEPHONE
FAX NO
EMAIL
YOUR POSITION
DATES WORKED
From
To
2ND REFEREE WORK RELATED
CONTACT NAME: MR/MS
HIS/HER POSITION
ORGANISATION
ADDRESS
POSTCODE
DAYTIME TELEPHONE
FAX NO
EMAIL
YOUR POSITION
DATES WORKED:
From
To
1ST REFEREE (CHARACTER)
CONTACT NAME: MR/MS
HIS/HER POSITION
ORGANISATION
ADDRESS
POSTCODE
DAYTIME TELEPHONE
FAX NO
EMAIL
YOUR POSITION
DATES WORKED
FROM
To
2ND REFEREE (CHARACTER)
CONTACT NAME: MR/MS
HIS/HER POSITION
ORGANISATION
ADDRESS
POSTCODE
DAYTIME TELEPHONE
FAX NO
EMAIL
YOUR POSITION
DATES WORKED
FROM
TO
ADDRESSES (Please List Your Addresses in The Past 5 Years.)
1.
FULL ADDRESS
DATE FROM
DATE TO
2.
FULL ADDRESS
DATE FROM
DATE TO
3.
FULL ADDRESS
DATE FROM
DATE TO
4.
FULL ADDRESS
DATE FROM
DATE TO
5.
FULL ADDRESS
DATE FROM
DATE TO
REHABILITATION OF OFFENDERS’ ACT 1974
Because of the nature of the work involved, the post for which you are applying is exempt from selection 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act (exemption order 1975). This means that you are not entitled to withhold information relating to any conviction you may have had.
If you answered YES to any of the above questions, please give information in writing below. This information will be treated as confidential and will not necessarily mean that we will not employ you.
DECLARATION
Please declare in writing below details of any instances where you were the subject of an INVESTIGATION or ENQUIRY into abuse or any other inappropriate behaviour and provide details of any reason why you would be considered to be unsuitable to work with children or vulnerable adults. If none, please declare this in writing below.
ASYLUM & IMMIGRATION ACT 1996
It is now a requirement that, before any offer of employment can be made, all candidates provide the company with confirmation of their eligibility to work in the United Kingdom by providing one of the original documents details below (Please tick the box if applicable):
All candidates must note that unless one of the above original documents has been produced no offer of employment will be made.
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.
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 (Please Tick as Appropriate)
NAME
POSITION
Experience
Specialist Care/ Training
Use of Equipment / Manual Handling Tasks
Personal Care
Daily Tasks
DIVERSITY MONITORING
NAME
POSTION
PLEASE TICK
DISABILITY
Are there any reasonable adjustments that would assist in you 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. The groups listed below reflect the largest ethnic groups in HCC. You are asked to choose the ethnic group that is closest to how you see yourself and write in a more specific group if you wish.
Any other White background – please specify.
Any other Asian background – Please specify.
Any other Mixed background – please specify
Any other Black background – please specify:
Any other Religion – please specify
NATIONALITY
Where did you see this post advertised?
QUESTIONNAIRE
NAME
DATE
DO YOU HAVE HISTORY OF
please specify
Have you been vaccinated against
Date:
Date:
Date:
Date:
If YES, please give details
Name & Address of General Practitioner:
Tel
How many working days have you been sick in the past 2 years?
Types of sickness in each of the last two years?
I declare the answers above to be true and correct in every aspect. I give the permission to the company to approach my own medical practitioner for further and better particulars of my medical history / records should the company so decide and for the submission of my medical reports to the company.
SIGNATURE
DATE
Send
