Application Form

PERSONAL DETAILS

Position Applied For*

Preferred Location*

Where did you hear of this vacancy?*

Surname*

Title*

Forename(s )*

Date and place of birth:*

Address:*

Tel. (Home)*

Tel. (Mobile)*

Email*

Do you hold a current full driving license?*

Yes
No

Do you have any current endorsements?*

Yes
No

National Insurance Number:*

Do you require a Work Permit to work in the U.K*

Yes
No

EDUCATION AND TRAINING

School/College/University*

Examinations Passed/Qualifications gained*

TRAINING HISTORY/PROFESSIONAL STATUS

Date of Graduation/Qualification*

Location/Details*

Notes*

EMPLOYMENT HISTORY

Current employer first. Must have 2 employer references and 1 character reference.

(1)

Name and address of your recent/last employer*

Date Employed

From*

To*

Position held and duties undertaken*

Salary / Rate*

Reason for leaving*

(2)

Name and address of Employer prior to the employer listed above*

Date Employed

From*

To*

Position held and duties undertaken*

Salary / Rate*

Reason for leaving*

(3)

Name and address of employer prior to the employer listed above*

Date Employed

From*

To*

Position held and duties undertaken*

Salary / Rate*

Reason for leaving*

Other Employment History (use additional sheet)*

Are there any gaps in your work History? If yes please explain the gaps*

ADDITIONAL INFORMATION

Do you have any mental or physical disability or illness (currently or recurring) which is relevant to the post for which you are applying?*

Yes
No

please give details:*

What adjustments (if any) need to be made to the working environment to accommodate your disability?*

Please give details of all absences from work in the last 12 months, except holidays*

Please give details of any illness/accidents/injuries in the last 2 years*

ELIGIBILITY TO WORK IN THE UK

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?*

Yes
No

please provide details:*

If you are successful in the application would you require a work permit prior to taking up employment?*

Yes
No

please provide details:*

REFERENCES

You must provide references from your two most recent employers. Please provide an additional character referee. All will be contacted, therefore please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please inform your interviewer immediately if you do not meet these specifications.

CURRENT OR MOST RECENT EMPLOYER

Name*

Address*

Phone*

Email*

Job Title*

PREVIOUS EMPLOYER TO THE ONE ABOVE

Name*

Address*

Phone*

Email*

CHARACTER REFERENCE

Name*

Address*

Phone*

Email*

Relationship with you*

Applicants Declaration – Read and understand before signing.

1. I confirm that the information given above is complete and correct, and I understand that any incomplete, untrue or misleading information given to the employer will entitle the employer to reject my application, withdraw any employment offer made, or, if I am employed, dismiss me without notice
2. I agree that the employer reserves the right to require me to undergo a medical examination to assess my suitability to work

I CERTIFY THAT I HAVE READ AND UNDERSTOOD THE ABOVE AND THAT THE INFORMATION I HAVE GIVEN IS TRUE AND CORRECT.

CONFIDENTIAL DECLARATION FORM

Before you can be considered for appointment in a position of trust with Caring Partners Healthcare LTD we need to be satisfied about your character and suitability.
Please read the following notes carefully before completing this declaration Form. If you require further information, please contact:

All enquires will be treated in confidence.
Caring Partners Healthcare aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation, age or offending history. We undertake not to discriminate unfairly against on the basis of criminal conviction or other information declared.

Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe has a bearing on your suitability for the position. If we do not raise information with you, this is because we do not believe that it should be taken into account. In that event, you remain free to discuss any of that information or any other matter that you wish to raise. As part of assessing your application, we will only take into account relevant criminal record and other information declared.

The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent before processing sensitive data about you. Processing includes: obtaining, recording, holding, disclosing destruction and retaining information.

Sensitive personal data includes any of the following information: criminal offences, criminal convictions, criminal proceedings, disposal or sentence. The information that you provide in this. Declaration Form will be processed in accordance with Data Protection Act 1998, and will only be used for the purpose of determining your application for this position.

This Declaration Form will be kept securely and in confidence, and access to it will be restricted to designated persons within Caring Partners Healthcare and other persons who need to see it as part of the selection process and who are authorised to do so.

Please answer all of the following questions? If you answer ‘Yes’ to any of the questions, please provide full details in the space indicated. Please also use the space below to provide any other information that may have a bearing on your suitability for the position for which you are applying. You may continue on a separate sheet if necessary and you may attach supplementary comments should you wish to do so.

The position for which you have applied is exempted from the Rehabilitation of Offenders Act 1974. This means that you must declare all criminal convictions, including those that would otherwise be considered “spent”. With the exception of question 8 answering ‘Yes’ to any of the questions below will not necessarily bar you from appointment. This will depend on the nature of the position for which you are applying and the particular circumstances.

1. Are you currently bound over or have you ever been convicted of any offence by a court or court-Martial in the United Kingdom or in any other country? Note: You do not need to tell us about parking offences.*

Yes
No

Please include details of the order bounding you over and/or the nature of the offence, the penalty, sentence or order of the court and the date and place of the Court hearing.*

2. Have you ever received a police caution, reprimand or final warning?*

Yes
No

Please include details of the caution, reprimand or final warning, including the date and reason administered.*

3. Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of? Please note: you must inform us immediately if you are charged with any offence in the United Kingdom or in any other country after you complete this form and before taking up any position offered to you. You do not need to tell us if you are charged with parking offences.*

Yes
No

Please include details of the nature of the offence with which you are charged, date on which you were charged and details of any on-going proceedings by a prosecuting body.*

4. Are you aware of any current police investigation in the United Kingdom or in any other country following allegations made against you?*

Yes
No

Please include details of the nature of the allegations made against you and if known to you, any action to be taken against you by the police.*

5. Have you ever been dismissed by reason of misconduct from any employment office or other position previously held by you?*

Yes
No

Please include details of the employment, office or position held, the date that you were dismissed and the nature of allegations of misconduct made against you.*

6. Have you ever disqualified from the practice of a profession or require to practice subject to specified limitations following fitness to practice proceedings by a regulatory or licensing body in the United Kingdom or in any other country?*

Yes
No

Please include details of the nature of the disqualification, limitation or restriction, the date and the name and address of the licensing or regulatory body concerned.*

7. Are you subject to any other prohibition, limitation, or restrictions that mean we are unable to consider you for the position for which you are applying?*

Yes
No

Please include details of the nature of the prohibition, restriction, or limitation when and by whom it was made.*

DECLARATION

I have read the “Guidance Notes for Applicants” that accompanied my application form, and I consent to the information provided in this Declaration Form being used by Caring Partners Healthcare for the purpose of assessing my application.

I confirm that the information that the information that I have provided in the Declaration Form is correct and complete. I understand and accept that if I withhold information or provide false or misleading information this may result in my application being rejected, or if I am appointed in my dismissal.

I CERTIFY THAT I HAVE READ AND UNDERSTOOD THE ABOVE AND THAT THE INFORMATION I HAVE GIVEN IS TRUE AND CORRECT.

EQUAL OPPORTUNITIES
The Caring Partners Healthcare is opposed to discrimination on any grounds. In particular, we oppose discrimination on the grounds of race, religion, ethnic origin, sex, sexuality, marital status, disability or age. The Caring Partners Healthcare is committed to ensuring that ability and potential for the job are criteria used for all staff selection.

MONITORING
The Company has adopted the provisions contained in the Code of Practice published by the Equal Opportunities Commission for Racial Equality and the Code of Practice published by the Equal Opportunities Commission that employers should regularly monitor the effects of selection decisions to assess whether equal opportunities is being achieved. For this purpose you are asked to complete and return the form below with your application form. This information is for statistical reasons only and will be treated as confidential.

APPLICATION FOR EMPLOYMENT

CURRENT OR MOST RECENT EMPLOYER

PREVIOUS EMPLOYER TO THE ONE ABOVE

CHARACTER REFERENCE

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