Midlands Care Homes - Job Application Form

Midlands Care - Job Application Form

This is a perfect opportunity for you to start a rewarding career in care. Complete and submit the form below.
Which home are you applying for?
Position:*
Where did you hear about the Job Opportunity:*
Full Time or Part Time?*
Full Name*

First NameMiddle NameLast Name
Title*
Any previous names and relevant dates. If none please state 'None'*
Contact Telephone Number*
Email Address*
Date of Birth*
City of birth*
Country of birth*
Nationality (For DBS purposes ONLY)*
Mothers Maiden name *
Your mother's LAST name before her marriage.
What is your Right to Work status?
Note: The company will require proof of this right before an offer of employment can be confirmed - eg. Birth certificate and/or any other appropriate document required to confirm your right to work in the UK as required by the Asylum and Immigration Act 1996.

Address History

You need to provide us with atleast FIVE years of address history.
What is your current address (inc postcode)*
When did you move to this address?

(Always Use the Calendar icon to select dates in this form.)
Date*
Previous address (inc postcode)
Date From*

DayMonthYear
Click the calendar icon
Date To
Taken from entry above
Previous address (inc postcode)
Date From*

DayMonthYear
Click the calendar icon
Date To
Previous address (inc postcode)
Date From*

DayMonthYear
Click the calendar icon
Date To
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Previous address (inc postcode)
Date From*

DayMonthYear
Click the calendar icon
Date To
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Previous address (inc postcode)
Date From*

DayMonthYear
Click the calendar icon
Date To
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Previous address (inc postcode)
Date From*

DayMonthYear
Click the calendar icon
Date To
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side

Absence Details

(NOT including sickness)
How many unplanned absences (NOT sickness) have you had during the last 12 months employment?*
Please provide details of these absences. If applicable please state 'None'.*
Additional Information
Do you have any disabilities and or injuries that we need to be aware of so that we can plan for and make reasonable adjustments to accomodate you should you be successful in your application?. Please state 'None' if applicable*

Employment History

Midlands Care require your FULL employment status history
Current Employer or reason for Non-Employment
Employment Status*
Current Employer or current School / College / University attended.
* Must be completed if you are employed
Please always use the calendar icon to select the dates
When did this employment (or non-employment) commence. *

DayMonthYear
We require FULL employment status history

Please list your previous employment status (DO NOT LEAVE GAPS)

(including periods of non-employment)

Most recent first
Employment Status*
Employer or School / College / University attended.
*Must be completed if you are employed
Date From*

DayMonthYear
Click the calendar icon
Date To
Reason for leaving:
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Employment Status*
Employer or School / College / University attended.
* Must be completed if you are employed
Date From*

DayMonthYear
Click the calendar icon
Date To
Reason for leaving:
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Employment Status*
Employer or School / College / University attended.
* Must be completed if you are employed
Date From*

DayMonthYear
Click the calendar icon
Date To
Reason for leaving:
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Employment Status*
Employer or School / College / University attended.
* Must be completed if you are employed
Date From*

DayMonthYear
Click the calendar icon
Date To
Reason for leaving:
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Employment Status*
Employer or School / College / University attended.
* Must be completed if you are employed
Date From*

DayMonthYear
Click the calendar icon
Date To
Reason for leaving:
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Employment Status*
Employer or School / College / University attended.
* Must be completed if you are employed
Date From*

DayMonthYear
Click the calendar icon
Date To
Reason for leaving:
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Employment Status*
Employer or School / College / University attended.
* Must be completed if you are employed
Date From*

DayMonthYear
Click the calendar icon
Date To
Reason for leaving:
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side
Employment Status*
Employer or School / College / University attended.
* Must be completed if you are employed
Date From*

DayMonthYear
Click the calendar icon
Date To
Reason for leaving:
Note: The 'Date From' entered above should be prior to the 'Date To' on the right hand side

Employment history beyond 5 years: (If applicable) *
Write 'Not applicable' if you do not have any employment prior to 5 years.

Please detail any relevant qualifications and experience that will support your application.

Because of the nature of the work for which you are applying, this post is exempt from the provision of sec4(2) of the Rehabilitation of Offenders Act (exempt order 1975).

Applicants are therefore not entitled to withhold information about convictions or cautions which are current or 'spent' under the provisions of the act and in the event of employment, any failure to disclose such convictions or cautions could result in disciplinary action or dismissal by the employer.

Any information given will be kept confidential and will only be used in consideration of the position applied for.

Please click here for more details on The Rehabilitation of Offenders Act 1974
Have you ever been convicted or cautioned of a criminal offence?*
If answered 'Yes' to the above please provide details. If no please state 'No'*
Have you ever been dismissed or suspended for any pending case?*
If answered 'Yes' to the above please provide details. If no please state 'No'*

Equality and diversity
Gender*
Age*
Ethnicity *
Do you consider your self to have disability or health condition?*
What is your sexual orientation?*
What is your religion or belief?*
What is your working pattern?*
What is your flexible working arrangement?*

Reference Requests

Complete the section below with details of who will be providing you a reference. We need a total of at least 2 reference. One must be from your current/past work place and another can be a character reference or a reference from another previous work place. We reserve the right to request a third reference if we will necessary.
FIRST: Person Providing Reference:*

First NameLast Name
Relationship*
Email*
example@example.com
Contact Telephone Number*
SECOND: Person Providing Reference:*

First NameLast Name
Email*
example@example.com
Relationship*
Contact Telephone Number*

Data Protection and Privacy Statement (in line with the GDPR Regulation guidelines 2018)

The information in this application form is requested in line with Midlands Cares privacy statement which can be viewed in full or on our website at www.midlandscare.co.uk or in any of our homes.

If your application is unsuccessful following the interview process, all application forms are destroyed and NOT held on file.

However, if you would like to be considered for a future position within our company, please consent below to allow us to hold your personal information securely for the internal business use and for a future application made by yourself. The information you provided in this form may be used for internal statistical analysis to help with our requirement processes.
Please indicate whether you would like us to hold your application details on file
Please note that we never share any personal data that would make you identifiable to anyone outside of our organisation and for further assurance, all our employees are subject to following strict confidentiality policies and procedures implemented by our senior management team at Midlands Care.
Please add any further information in support of your application
Do you have a driving license?*
Not required but asked for the record.
How did you hear of this job opportunity?
Please note that any approval of this 'application' by Head Office is only the first stage of the application process. The homes management team still reserve the right to offer / not offer any employment.
Date of Application*

DayMonthYear
Date
Have you had the Covid-19 vaccine?*
Have you had both doses?
What date did you have your first dose?

MonthDayYear
Date
What date did you have your second dose?

MonthDayYear
Date
Have you got a Covid Pass
Signature

Clear
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Midlands Care - Job Application Form

Equality and diversity

Reference Requests