Home Care Application Form

Position Applied For
Willing to apply for DISCLOSURE to the Criminal Records Bureau     yes   no
PERSONAL DETAILS
Full Name
  Mr Mrs Miss
Address
Post Code
Telephone Number
Mobile
Place of Birth
Are you a Citizen of the EU or EEA? yes   no
If “ No”, do you have a Work permit? yes   no
   
HEALTH & DISABILITIES
Do you have any disabilities which may be relevant to this Job Application:    yes   no
If Yes, please describe them:
Are you Registered Disabled? yes   no
Overall State of Health: excellent   good poor
Hearing: excellent   good poor
Eyesight: excellent   good poor
Do you wear any of the following: Spectacles Contact Lenses Neither
Please give details of any medical condition for which you have received treatment in the past 5 years:
Have you had treatment for any condition relating to the abuse or mis-use of drugs or alcohol within the last 5 years?   yes   no
If “YES” please provide brief details
Would you be willing to have a medical examination if required ?   yes   no
   
DRIVING RECORD
   
Do you have a current clean “FULL” driving licence?    yes   no
If “YES”, for what classes of Vehicle
Driving licence valid from: To:
Number of Penalty Points (if any) endorsed on current licence:   
Have you ever been disqualified from driving, or had insurance refused?  yes   no
If “Yes”, please provide brief details:
   
GENERAL EDUCATION
   
From
To
Name of school
From
To
Name of College
           
Examination results/qualifications obtained
 
   
EMPLOYMENT
   
Name and Address of Current Employer
(or last Employer if currently unemployed)
Job Title and main duties
Employment Dates
From
To
Reason for Leaving: Average gross pay: £ per week/month/annum
   
Previous Employment (Employer Name and your Job Title)
   
Referees
       
Name Name
Address Address
Telephone Telephone
May we contact them at this stage? May we contact them at this stage?
yes   no yes   no
   
JOB FLEXIBILITY
   
Prepared to Work:           Full-Time    Part-Time    Shifts
If Part-Time please indicate preferred hours:
Details of any other work which you will continue to undertake if you are offered this Job Position:
Please provide details of any outstanding holidays to be taken:
AVAILABLE TO TAKE UP EMPLOYMENT FROM:
   
REHABILITATION OF OFFENDERS ACT, 1974
 

Through the 1975 exemptions Order of the Rehabilitation of Offenders Act, 1974, and by virtue of the nature of the post for which you are applying, we are obliged, as your prospective employers, to ask the following question. Any information supplied by yourself will remain confidential and considered only in relation to the Job Application:

With the exception of minor motoring offences, have you ever been convicted of any criminal offence by a Court of Law?
yes   no
If “YES” please provide brief details of the offence(s) and relevant dates:
   
EQUAL OPPORTUNITIES – VOLUNTARY INFORMATION
 
The organisation seeks to recruit employees on the basis of their general suitability for a position and aims to ensure that consideration of age, sex, marital status, disability and racial or ethnic origin should play no part in this process.

In order to monitor the effectiveness of this commitment to equal opportunities it would be helpful if you could complete this section of the form. Completion is not compulsory but should you give details below the information will be used for no other purpose than that as stated in this paragraph.
Marital Status          Single Married Separated Widowed Divorced
Sex          Male Female
Ethnic Origin         African Afro-Caribbean Asian European Polynesian
Disabilities (specify)
Registered Disabled Number (where relevant)
   
DECLARATION - please read carefully, then date and submit your application.
   
I confirm that the information I have provided is correct and understand that misleading statements may be sufficient grounds for cancelling any agreements made. I also understand that questions left unanswered may be discussed at interview(s) arising from this application:
Date