Please complete all sections on this form

Data Protection Statement The personal information (data) collected on this form, are used only for the purpose of this employment. Equality of Opportunity Statement The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.

Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home. Please use separate sheet if insufficient space is available.

Any offer of employment may be made subject to a satisfactory medical report.

Your GP will never be contacted without your approval

Note: Minimum age legislation dictates that Care workers in general must be 16 years old or older. Please inform your interviewer immediately if you do not meet these specifications.

You must provide references from your two most recent employers. Please provide an additional character referee. 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.

SIGNATURE and DECLARATION IMPORTANT BEFORE SIGNING

I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately. I understand that I may not be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise Revive Health Care to request a DBS Register check and a criminal record check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred Care workers, or withdrawal of any registration required by my employment status.

Workers of Revive Health Care are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions. Please note, you may not be eligible for work in a Care setting if you are on the DBS Register(s).

EQUAL OPPORTUNITIES MONITORING FORM INTERVIEWER – DETACH THIS FORM FROM THE PACK AND HAND IT TO THE CANDIDATE, TOGETHER WITH A STAMPED ADDRESSED ENVELOPE. NO MARKS TO IDENTIFY THE CANDIDATE MAY BE MADE – THE REPLY IS ANONYMOUS AND CONFIDENTIAL. • Revive Health Care is committed to promoting equal opportunities for all its employees and all prospective employees. • To ensure that all applicants are dealt with equally, we wish to monitor your recruitment process and would ask for your help by completing the details below by placing a 'tick' in the appropriate box. This will allow the organisation to monitor its policies. PLEASE NOTE • You do not have to complete this form. The information is given on a voluntary basis and the information provided will only be used for the monitoring purpose. • Please do not enter any identifying marks on this form, so that your information remains confidential. This information will be stored on a computer.

DISABILITY The Equality Act 2010 defines a disability as a "physical or mental impairment which has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities". An effect is long-term if it has lasted, or is likely to last, more than 12 months.