Health Care Worker Application Form
Please complete all sections on this form
Position Applied For
Title
Please Select
Mr
Mrs
Miss
Ms
Name
First Name
Last Name
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.
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The completion of this application form is part of stage one. This application will be reviewed, and a decision made as to whether to proceed to stage two, the interview, based on this information. PLEASE COMPLETE FULLY AND IN CAPITALS.
Position Applied For
Approx number of hours wanted
Select working Time
Full
Part Time
Preferred Shift
Days
Evenings
Weekends
Afternoons
Mornings
Title
Please Select
Mr
Mrs
Miss
Ms
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Previous Names (supply documentary evidence)
Documentary evidence
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Current Address
Street Address
Street Address Line 2
City
Postal Code
County
Please provide previous addresses if available, dating back to 5years
Email Address
example@example.com
Phone Number
Do you have own transport?
Yes
No
Clean Current Driving License
Yes
No
If held, please provide details of how long the license has been held and endorsements if available.
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Education
Add Educational Qualifications
*
Training History/Professional Status
*
Please upload copies of your certificates
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Choose a file
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Employment History
Details of past employment starting with the most recent
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.
Experience
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Assistance with Interview and Assessment
Do you require us to make any special arrangements in order for you to participate in the recruitment process? For example, large print forms? Or additional time to complete forms?
Yes
No
Any offer of employment may be made subject to a satisfactory medical report.
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GP Details
GP's Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Your GP will never be contacted without your approval
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Next of Keen
Name
First Name
Last Name
Relationship
Phone Number
Address
Street Address
Street Address Line 2
City
county
Postal Code
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Identity Details
Nursing and Midwifery Council Pin Number (Nurses Only)
National Insurance Number (All Applicants)
Capacity to work in UK
Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?
Yes
No
If Yes, Please provide details
If you are successful in the application, would you require a working permit prior to taking up employment
Yes
No
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.
References
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.
Add your references (starting with the current or most recent one)
Character reference
Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not and warnings and cautions in the space provided below.
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 Charismatic Care Limited 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.
Date
-
Month
-
Day
Year
Date
Signature
Workers of Charismatic Care Limited 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. • Charismatic Care Limited 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.
Gender
Male
Female
Prefer no to say
Do you identify as transgender
Yes
No
Prefer no to say
Ethnic Group
White
British
English
Scottish
Welsh
Irish
Other White backgrounds
Mixed race
White and Black Caribbean
White and Black African
White and Asian
Other mixed backgrounds
Asian or Asian British
Indian
Pakistani
Bangladeshi
Other Asian backgrounds
Black
African
Caribbean
Other Black backgrounds
Chinese and Other groups
Chinese
Other ethnic group
Age
Please Select
16–17
18–21
22–30
31–40
41–50
51–60
61–65
66–70
71+
Prefer not to say
Sexual Orientation
Please select below
Heterosexual
Bisexual
Gay man
Gay woman / lesbian
Prefer not to say
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.
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