FirstCare (GB) Ltd Enabling a life of fulfilment

Job Application

First Care (GB) Ltd Registered Offices: First Care (GB) Ltd 3rd Floor. Howard House, 40-64 Johns Street MK42 0DJ Tel: 01234865087 Email: hr@firstcaregb.co.uk
Position Applied*
Title*
Full Name*
Birth Date*

DayMonthYear
Current Address

Street Address

Street Address Line 2

City

Post Code
Email Address*
Home Phone Number

Area CodePhone Number
Phone Number*

Area CodePhone Number
Proof of Right to Work in UK
Place of birth*
Nationality*
YesNo
(If you have answered yes please complete this section)
YesNo
YesNo
Next of kin details
Next of kin Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Post Code
Phone Number*

Area CodePhone Number
Relationship*
Education

Rows	Name and Address of Secondary School/colleges	Date attended (from-to)	Grade/Mark (e.g. GCSE,Diploma, HNC Etc)
1
2
3
3
5

TRAINING -Please list all relevant training previously undertaken (please provide Evidence e.g. Certification or CPD Profile)

Rows	Training Course	Date or last Certificate	Date of update required
1
2
3
3
5

EMPLOYMENT

Please give full details of a 10 years employment history, this should include any gaps in employment suchas “home maker, bringing up children, unemployment, Medical Leave etc)

Rows	Name and address of employer	Position Held	Start	Finish	Reason for leaving
1
2
3
3
5
6

Working Time Directive
The European Union has laid down Guidelines for all worker, governing the length of maximum working week that is safe to work. The current limit is 48 hours per week.

Because you are under no obligation to accept work offered, you will never be compelled to work more than 48 hours per week, but you may choose to do so.

Please sign the box below to confirm that you have read and understood the above information, indicating your preference by tickling the most appropriate statement.
I DO NOT wish to work more that 48 hours per weekI DO wish to work more that 48 hours per week
Signature*

Clear
References
We require Names and contact details of two referees, one of these must include your current or most recent employer. These should not be relatives or friends and they must be able to provide a credible comment on your ability to undertake the duties of the post applied for:

(For employee reference an office address and work email should be provided)
Reference 1 (current or most recent employer)*
Reference 2 *
Reference 3
Declaration
The information I have given in this application form is to the best of my knowledge, complete ad accurate in all respects.

I understand that knowingly given false information will disqualify me from registration with this agency.

I also agree to keep FirstCare (GB) advised of any changes to any information.
Name

First NameLast Name
Date

DayMonthYear
Date
Signature*

Clear

Rows	Name	Address	DOB

Rows	GP Name	Surgery Address	Telephone number

Should be Empty:

Rows	Date	Result
Tetanus
Diphtheria Schick test
Rubella (German Measles)
Poliomyelitis
Hepatitis B
Booster (Hep B) (date of result.)
Tuberculosis BCG
Chest X-ray
Varicella

Rows	1	2	3	4
Bath / Shower / Assisted Wash
Use of bath aids
Mouth Care (including dentures)
Care of feet (excluding toe nails)
Dressing / Undressing of patients
Bed bath
Shaving
Care of hair
Care of finger nails
Care of eyes
Pressure area care

Rows	1	2	3	4
First Aid
Awareness of Health safety
Bed Making
Simple Dressing
Report Writing/ Handover
Laundry
Shopping
Domestic Duties

Rows	1	2	3	4
Moving & Handling
Use of Hoists
Use of Walking Aids
Use of wheel chairs

Rows	1	2	3	4
Caring for MRSA positive patients
Barrier Nursing
Isolation
Universal precautions
Hand Washing
Cross infection

Job Application

Proof of Right to Work in UK

Next of kin details

Education

EMPLOYMENT

Working Time Directive

References

Declaration

Declaration of Health

SKILLS PROFILE

Equal opportunities monitoring form

Rows	1	2	3	4
Emptying and changing a catheter bag
Catheter Care
Use of bedpans and Bottles
Collection of stool /Urine samples
Incontinence care

Rows	1	2	3	4
Sheaf / Convene
Hospital / NHS
Nursing Home
Residential Home
Hospice
Private Hospital
Home Care
Escort
Specialising

Rows	1	2	3	4
Elderly people
Dementia
Palliative care / care of terminally ill
People with physical disabilities
People with mental health problems
People living with HIV / AIDS
Children / families
Learning disability
Mental Health
Acute
Moving & Handling Course
Basic Care & Observation Course
First Aid Course
Basic Food Hygiene Certificate