New Star Care Application Form

Application Form - Private & Confidential

Support Worker/Care Assistant - Email to newstarcareagency@gmail.com
Full Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Date of Birth

DayMonthYear
Gender
NI Number
Do you have your own transport
Do you have the right to work in the UK
Passport Number
Nationality
Passport Expiry Date

DayMonthYear
Bank Name
Account Holder Name
Sort Code
Account Number
Employment History (for the last 5 years)
Starting from Current or last employer
Employer Name and Address
Date From

DayMonthYear
End Date

DayMonthYear
Employer Name
Date From

DayMonthYear
End Date

DayMonthYear
Employer Name
Date From

DayMonthYear
End Date

DayMonthYear
Rehabilitation of Offenders Act 1974
In the past 5 years, have there been any disciplinary actions taken against you by your employer or contractor either in the UK or outside - that have been upheld?
If you answered YES please explain
In the past 5 years, has your employment or contract ever been terminated or suspended - in the UK or ourside on the grounds relating to your fitness to practice (conduct, performance or health)?
If you answered YES please explain
Have you ever been subject to any safeguarding proceedings?
What was the outcome?
If you were subject to a safeguarding issue what would you do?
After a Disclosure has been obtained, the applicant is reuired to inform the Agency immediately of any conviction(s), caution(s), or reprimand(s) or inclusion on the Protection of Children Act or Protection of Vunderable Adults registers, which occur after their commencement with New Star Care Limited. Failure to do so may result in disciplinary action.
Referee #1 (Previous/Current Employer Name)
Referee #1 Email Address
Referee #2 Name and Position
Referee #2 Email Address
DBS Certficate Number
Date of Issue

MonthDayYear
Date

MonthDayYear
I hearby confirm that all the information in this application is true to the best of my knowledge.
Signature
Date

MonthDayYear
Date
Should be Empty:

Application Form - Private & Confidential