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*

MaleFemaleN/A
NI Number
Do you have your own transport*

YesNo
Do you have the right to work in the UK

YesNo
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?*

YesNo
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)?

YesNo
If you answered YES please explain
Have you ever been subject to any safeguarding proceedings?*

YesNo
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

Clear
Date

MonthDayYear
Date
Should be Empty:

Application Form - Private & Confidential