Centrum Care Homes Application Form

Centrum Care Homes Application Form

This form will be kept in confidence. Please note that no applicant will be unfairly discriminated against. This includes discrimination on account of age, cultural/religious/political belief, disability, ethnicity, gender, race, relationship status, sexual orientation, and/or Trade Union membership or stewardship. If you have any special requirements to support you to complete this form (e.g. need a printed copy or large print) please contact HR at recruitment@centrumcarehomes.co.uk.
Position
Position applied for*
Care Home/Location applying to*
Preferred employment type (e.g. part time, full time)
Personal Details
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

TownCounty

Post Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Own Transport?*
How long has your licence been held?
Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National*
If no, please detail current immigration status and the relevant visa currently held (including Visa number)
National Insurance Number*
Are you related to a member of staff or Service User at Centrum Care Homes? If yes, please provide the relative's name*
Emergency NOK Name*
Relationship to you *
Contact Number*
Equality Act 2010

Under the Equality Act 2010 the definition of disability is if you have a physical or mental impairment that has a “substantial” and “long term adverse effect” on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-under-equality-act-2010.
For the purposes of this application and the interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?*
Education

All qualifications will be subject to a satisfactory check
List here Schools/Colleges/Universities attended*
List here examinations passed, qualifications gained and year obtained*
Training Courses Attended or Completing

List Subject, location details and dates
Subject / Location / Date*
Employment History

Please record below the details of your full employment history beginning with your current or most recent first. Please detail a career history from the age of first employment. This information may be in the form of a Curriculum Vitae which you may attach to your application. Employment Information must outline all periods of employment or self-employment, showing beginning and end dates, (actual or approximated month and year), together with an explanation of periods of non-employment..
Have you worked before?*
If you have not worked before, please move on to the next section
Name and address of your most recent/last employer*
Start date*

DayMonthYear
Date
End date*

DayMonthYear
Date
Nature of business*
Position held*
Reason for leaving*
Salary / Pay Rate
Name and address of employer prior to the employer listed above*
Start date*

DayMonthYear
Date
End date*

DayMonthYear
Date
Nature of business*
Position held*
Reason for leaving*
Salary / Pay Rate
Name and address of employer prior to the employer listed above
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Nature of business
Position held
Reason for leaving
Salary / Pay Rate
Name and address of employer prior to the employer listed above
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Nature of business
Position held
Reason for leaving
Salary / Pay Rate
Name and address of prior to the employer listed above
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Nature of business
Position held
Reason for leaving
Salary / Pay Rate
Name and address of employer prior to the employer listed above
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Nature of business
Position held
Reason for leaving
Salary / Pay Rate
Name and address of employer prior to the employer listed above
Start date

DayMonthYear
Date
End date

DayMonthYear
Date
Nature of business
Position held
Reason for leaving
Salary / Pay Rate
Please detail any other employment you have had if not mentioned above
Include name and address of employer, start and end date, nature of business, position held, reason for leaving
Please detail here any gaps in employment and state why*
Supporting statement
Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe particular strengths and talents that set you apart from others as well as including skills gained from work, home and other activities*
Referees

You must provide references from your two most recent employers. Please provide a character reference if you are unable to obtain two professional references, e.g. in the case of an applicant who has been raising children for ten years. 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 discuss the matter with us.
Current or Most Recent Employer
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

TownCounty

Post Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Job Title*
Previous Employer to the One Above
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

TownCounty

Post Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Job Title*
Character Reference

This may be from a friend, neighbour, teacher or tutor, work colleague and must NOT be a family member.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

TownCounty

Post Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship to you*
Safeguarding - Ex-Offenders Declaration

Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest of confidence.
Rehabilitation of Offenders Act 1974

Centrum Care Homes aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. Cenrum Care Homes undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.
Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.
Are you currently bound over or do you have current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or any other country?*
Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country?*
File Upload

Upload CV, certificates or anything that will be useful to support your application
Cancelof
Declaration

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by Centrum Care Ltd. Where applicable, I consent that Centrum Care can seek clarification regarding professional registration details.
Name*

First NameLast Name
Date*

DayMonthYear
Date
Signature*

Clear
Should be Empty:

Centrum Care Homes Application Form

Position

Personal Details

Equality Act 2010

Education

Training Courses Attended or Completing

Employment History

Supporting statement

Referees

Current or Most Recent Employer

Previous Employer to the One Above

Character Reference

Safeguarding - Ex-Offenders Declaration

Declaration