APPLICATION FORM

Position Applying for

Personal Particulars

Prefix

Full Name

First NameLast Name

Marital Status

Single

Married

Divorced

Widowed

Date of Birth

Country of Birth

Nationality

National Insurance Number

Bank Details

Bank Name

Sort Code

Account Number

All details are held in the strictest confidence under the Data Protection Act 1998.

I authorize Betta Care Concepts to make payments to this account for work done

Date

Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Mobile Tel. No.

Please enter a valid phone number.Format: (000) 000-0000.

Correspondence Address (If different from above)

Street Address Line 2

Educational Qualifications

Professional Qualification

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Proficiency in Languages

Native Language

Second Language (optional)

Proficiency In Speaking Second Language

Proficiency In Writing Second Language

Type a Proficiency In Reading Second Language

Third Language (optional)

Proficiency In Speaking Third Language

Proficiency In Writing Third Language

Proficiency In Reading Third Language

Do You Hold a Full Uk Driving License Or Equivalent

Details Of Any Endorsement

Do You have A Car

Skills (Nursing)

Skills (Others)

References

Health Questionaires

An answer must be provided for all questions. The information will be treated in confidence.

GP Name

GP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

GP Tel. Phone

Please enter a valid phone number.Format: (000) 000-0000.

Medical History

Please complete the following questions by ticking the appropriate box. If the answer is "yes', give details including (a) date, (b) amount of time lost from work/school, (c) treatment, as appropriate.

Have you ever suffered from any of the following illnesses?

Visual defects/eye conditions (including colour-blindness)

If yes please provide details

Hearing defects/ear conditions

If yes please provide details

Severe anxiety, depression, other psychiatric disorder

If yes please provide details

Paralysis or other neurological disorder

If yes please provide details

Fainting attacks, blackouts, epilepsy or fits

If yes please provide details

Fainting attacks, blackouts, epilepsy or fits

If yes please provide details

Vertigo, giddiness or tinnitus

If yes please provide details

Heart disease, high blood pressure

If yes please provide details

Asthma, bronchitis, tuberculosis or other chest disease

If yes please provide details

Peptic ulcer or other digestive or bowel disorder

If yes please provide details

Liver disorder

If yes please provide details

Kidney of Bladder problems

If yes please provide details

Gynecological Problem

If yes please provide details

Recurrent backache, arthritis, rheumatism

If yes please provide details

Eczema, dermatitis, other skin conditions

If yes please provide details

Any blood disorder

If yes please provide details

Ever undergone a surgical operation or been admitted to hospital for any reason?

Had more than 20 days sickness absence in the past 2 years?

Yes

No

If yes please provide details

Ever been, or are a Registered Disabled Person?

Yes

No

If yes please provide details

Suffered from an Industrial Disease/Accident?

If yes please provide details

Had a chest X-ray in the past 12 months - If so state place / date / result

If Yes please provide details

Betta Care Concepts Healthcare DBS Check

Follow the link:- www.dbsdirect.co.uk

Then click on - Mayflower Disclosure Services Ltd

and Application log in: :(Orange box)

Organization Reference:BETTA CARE CONCEPTS

Organization Code: BETTA CARE CONCEPTS

Supporting Statement

Please state why you believe you are a suitable candidate for this post by explaining how you meet the requirements of the job description and the experience you have gained which is relevant. Please give examples of particular achievements.

Additional Information

Earliest Date Available If Appointed

Date

Have you had any criminal convictions (including spent convictions under the rehabilitation of offenders Act 1974)?

Yes

No

Yes

Are you subject to any restrictions from previous employers which may restrict your working activities?

Have you ever been employed by this company or its affiliates before?

Yes

No

Have you applied for employment with this company before?

Yes

No

Are you related to any employee working at this company?

Yes

No

Do you have any physical impairment or health problem?

Yes

No

Have you been dismissed or suspended from the service of any employer?

What are your weaknesses?

Are you bound by any bond to serve the government, or any organization?

If yes to any of the above, please give details here

Interview Questionaire

Full Names

First NameLast Name

Position Applied for

What are your Strengths?

What are your Weaknesses?

What are your goals?

What makes you a good candidate for this job?

If you encountered a service user who was upset what would you do?

If you encountered a service user who was being aggressive towards you or another resident how would you deal with it?

How would you transfer a resident from a bed to a wheelchair?

What is a care plan? Why should it be kept up to date?

Describe what you would do if a service user were to have an accident? Who would you report this

What is the purpose of a hand-over?

Describe what you would do if a service user were to have an accident? Who would you report this to?

What does 'Promoting Independence' means?

How would you promote infection control?

How would you dispose of clinical waste?

What items do you use to prevent the spread of infection?

What would you do if you witnessed another employee stealing?

What would you do if witnessed another employee being aggressive with a service user?

What would you do if you witnessed another employee not abiding by health, safety and infection control policies?

What would you do if you were uncertain of what to do on a shift?

What would you do if you did not understand or felt you didn't have enough training in certain areas of mandatory expectations?

You confirm that everything completed in this section is correct and attest to your character?

Date

Terms Of Engagement

Contract For Services

Thank you for applying to BetaCare website (the "Site" These terms & conditions ("Terms and Conditions") apply to the Site and its application service which reference these Terms and Conditions. Kindly review the Terms and Conditions listed below diligently prior to submitting this form as your submission on this website indicates your agreement to be wholly bound by its Terms and Conditions without modification. You agree that if you are unsure of the meaning of any part of these Terms and Conditions or have any questions regarding the Terms and Conditions, you will not hesitate to contact us for clarification.

click here to review

Temporary Worker's Full names

First NameLast Name

You acknowledge that you have read and agreed to the terms and conditions of the contract attached herewith?

Date

Declaration

I certify that all entries are true and correct. I understand that all information on this application is subjectto verification. I agree and understand that, in the event of my employment by Betta Care Concepts, I shall be subject to dismissal if any information that I have given in this application is false or misleading, regardless of time of discovery. I undertake to notify Betta Care Concepts of any changes in my circumstances, including health,criminal convictions and driving license endorsement, which would or could affect my ability to work. I understand that Betta Care Concepts may release my personal details to a client in order to secure work or to enable the client to verify my identity or eligibility to work. These details may include name, age, driving license,work history, criminal record, health questionnaire and proof of identity or eligibility to work. I authorizethe Betta Care Concepts to inquire into my educational, professional and past employment history references asneeded to research my qualifications for this position. I hereby give my consent to any former employerto provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I hereby acknowledge that I have read and agree to the above statements

Date