Care Ever

Personal Details

Post Applied

Title

Surname

Forename

Date of Birth

NI Number

Present Home address

Post Code

Mobile

Present Home Landphone

Email Address

Permanent Home address

Tel

Work Address (if applicable)

Work Tel

*Next Of Kin OR Emergency contact

Emergency Tel

Do you require a work permit?

Yes

No

If No please give Current Visa Details

Do you hold British passport?

Yes

No

Born in UK?

Yes

No

Do you have current valid DBS?

Yes

No

If yes Please give Ref No

Do you hold a current driving licence?

Yes

No

Do use your own vehicle for work?

Yes

No

2)Education

Degree, Diploma, GCSE`s and other Professional Qualification held or being studied for

School /College/University	Qualifications and Result	Date Attended

3)Training Record

Organisation/ College	Qualification	Date Attended

4)Employment History

Present or last employment

Name and address of present or most recent employer

Title of post

Date (From – To)

Reason for leaving

Brief description of duties and responsibilities

Full past employment history

Most recent first-either paid, voluntary or work at home

Employer	Post	From-to	Reason for leaving

References

The first referee should be your present / most recent employer (someone in a managerial position); the second person should be someone who is able to comment on your ability to do the job. Personal references are only accepted if you have not been previously employed. If you do not wish us to contact either or both referee before interview, please put X in the boxes below.

Referee 1

Name
Address
Position
Phone No
Email

Referee 2

Name
Address
Position
Phone No
Email

Other Information

Please give details of relevant experience and any other information in support of your application

6) Health

Please state if you have any health problems

Have you been a hospital in-patient, in the last two years? if so please give details

How many days sickness have you had in the last two years?

7) HEALTH QUESTIONNAIRE

*NB: Please provide proof of vaccination

Are you suffering from or have you suffered from	Yes	No	If Yes Please give details
Back, neck pain Shoulder or other aches and pains
Rheumatic or Arthritic conditions
Diabetes
Upper limb disorder such as tenosynovitis, tendonitis or carpel tunnel syndrome
Skin diseases or dermatitis
Fits, fainting attacks or epilepsy
Depression, anxiety or nervous illness, or have you been referred for psychiatric assessment
Typhoid, paratyphoid, food poisoning or recurring diarrhoea
Ear ache or ear infection
Tuberculosis or Hepatitis
Allergy (to any drugs or handling any substances)
Any illness or medical condition not specified above
Have you ever lost time from work as a consequence of one of the above conditions
Are your currently on medication, or undergoing any treatment
Do you smoke?
Have you ever taken time off work due to an illness or accident for two weeks or time
Have you ever been in receipt of state benefit as a consequence of an illness or injury arising from work
Have you ever been awarded compensation for an injury or illness arising from your work
Have you any permanent disability or are you registered disabled
Have you ever been refused employment or dismissed on medical grounds
Do You wear Glass
Do you have Dyslexia
Have you taken Covid 19 vaccination
*NB: Please provide proof of vaccination

I declare that the statements given above are true.

I understand that the non-disclosure or suppression of any relevant facts known by me may prejudice my application, or if appointed could lead to the termination of my employment.

I agree that a medical report may be obtained from my doctor or hospital specialist.

8) Disclosure Information

Because of the nature of the work concerned, this post is exempt from the provision of section 4 (2) of the rehabilitation of offenders act 1974. You are not entitled to with-hold information about convictions which for other purposes are spent under the provisions of the act. Any information given will be completely confidential and will be considered only in elation to your application for the post. In order to fulfil the requirements of the above mentioned act would you please complete he following:

1: Have you been convicted of a criminal offence, been bound over, cautioned or are you currently the subject of any police investigations/actions, which might lead to a conviction, an order binding you over or a caution in the united kingdom or any other country?

Yes

No

If yes please give details

2: Have you ever been or are you currently subject to any fitness to practice proceedings by an appropriate licensing or regulatory body in the united kingdom or any other country?

Yes

No

If yes please give details

3: Have you ever been dismissed from employment?

Yes

No

If yes please give details

9) Disclosure Information

I understand that if I am offered an appointment, it will be subject to the information given on this form being correct to the best of my knowledge, recognising that any incomplete or incorrect information could lead to dismissal.

* We hereby inform you that any changes to your circumstances including changes to your contact details, immigration status, etc should be reported to the Manager with immediate effect. Failure to do so will result in disciplinary actions being initiated against you

Job Application Form

Personal Details

2)Education

3)Training Record

4)Employment History

Present or last employment

Full past employment history

References

Referee 1

Referee 2

Other Information

6) Health

7) HEALTH QUESTIONNAIRE

8) Disclosure Information

9) Disclosure Information