Community Care Team Application Form [E]

Candidate Name*

PrefixFirst NameLast Name

Position applied for

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Country of Birth*

Date of Birth*

Date

Phone Number.*

Area CodePhone Number

National Insurance Number.*

Right to Work: Are you currently permitted to work in the UK?*

YesNo

How did you hear about the position?*

Disclosure & Barring Service (DBS) - Do you currently have a DBS on the DBS Update Service*

YesNo

Please enter your DBS Update Reference Number.*

Covering Letter - please detail what makes you a suitable candidate.*

Do you have a full driving license and access to a vehicle for work purposes?*

YesNo

What mode of transportation do you intend to use for work?*

WalkCycleMotorbikeScooter

Do you have previous experience in a caring role?*

YesNo

Please add a brief discription of experience .*

Do you hold any Social Care related qualifications?*

YesNo

Please add a brief description of qualifications .*

How many hours are you looking to work each week?*

0-10hrs10-20hrs20-30hrs30-40hrs

Do you have any restrictions to your availability to work each week?*

YesNo

Detail restrictions here.*

What is your current required notice period?*

What is your earliest available start date?*

Date

Education, Training & Employment History - Please attach your CV here*

Rehabilitation of Offenders - Failure to disclose any convictions which are not "spent" may render you liable for dismissal.

Have you any convictions which are not regarded as "spent" under the Rehabilitation of Offenders Act 1974?*

YesNo

Yes - Please give details of the offence and date of conviction.*

Are you currently the subject of any criminal proceedings or convictions?*

YesNo

Yes - Please give details of the current actions against you.*

Declaration by job applicant - Any person, upon subsequent employment, that is found to have knowingly supplied false or misleading information, or has deliberately withheld relevant information, may be subject to disciplinary proceedings which may result in dismissal.

I have read and understood the information supplied to me in relation to this Job Position, and the information requested in this Job Application Form. I confirm that all information supplied by me is true and correct to the best of my beliefsI give consent for a third party, to view my employment file for compliance or inspection purposes

Agreement and Declaration*

I will maintain the confidentiality of all the service user records and any other information that involves their care / medical management of the patient.I shall not disclose service user information in any manner that causes any harm to the service user or the relatives of the service user in any manner.I shall keep all medical history records / information which include papers, images, and reports of the patient in a confidential manner.I shall maintain confidentiality with regard to the verbal discussion and observation about the patient.I shall withhold all personal information of the patient such as social security number, telephone number, mailing address, spouse details, key safe code etc.I shall withhold all personal information of the patient such as social security number, telephone number, mailing address, spouse details, key safe code etc.By putting my name (signing) below, I acknowledge to have read and understood all the clauses specified and signify my compliance to all the clauses specified herein above. In the event of violation of any of the clauses specified above the patient has the right to take appropriate action against me.

Equality and Diversity Monitoring

To which gender do you most identify?*

What is your Marital Status?*

What is your Nationality?*

Please describe your ethnic origin.*

Please describe your religion/belief.*

Please select your age range.*

The Equality Act 2010, provides for disabled people to have a legal right to fair treatment in employment matters. When answering this question please note that the Equality Act 2010 defines a disability as “a mental or physical impairment which has a substantial and long-term adverse effect upon a person’s ability to carry out normal day-to-day activities”.

Please provide a description that best describes your impairment.

Date of Submission*

Date

Name*

PrefixFirst NameLast Name

Signature*