Celtic Care Application Form

Employment Application

Please complete the form below accurately and with as much detail as you are able.
Please attach a recent photograph

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Title
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

City/TownCounty

Postal Code
Birth Date

DayMonthYear
Phone Number
Phone Number
E-mail Address:
National Insurance Number:
Please provide
How were you referred to us?
Others:
Please provide details
Do you have the legal right to work in the UK?
If YES, but there are conditions, please specify what these are:
Please provide details
Do you hold a full UK driving licence?
Do you have use of your own vehicle?
Do you have any endorsements on your licence?
If YES, please specify penalty codes and dates of offences:
Please provide details
Job Skills & Training
Describe your skills:
Training or Certifications:
References

Please list at least two (2) references that are familiar with your work life. Reference 1 must be your most recent employer.
Reference 1
Name:

First NameLast Name
Email
example@example.com
Phone Number
Phone Number
Years Known:
Address

Street Address

Street Address Line 2

City/TownCounty

Post CodeCountry
Reference 2
Name:

First NameLast Name
Email
example@example.com
Phone Number
Phone Number
Years Known:
Address

Street Address

Street Address Line 2

City/TownCounty

Post CodeCountry
Reference 3
Name

First NameLast Name
Email
example@example.com
Phone Number
Phone Number
Years Known:
Address

Street Address

Street Address Line 2

City/TownCounty

Post Code
Reference 4
Name

First NameLast Name
Email
example@example.com
Phone Number
Phone Number
Years Known:
Address

Street Address

Street Address Line 2

City/TownCounty

Post Code
Criminal Record Declaration
Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section. 2(4)(2) of the Rehabilitation of Offenders Act 1974 (Exemption order 1975). Applicants are therefore not entitled to withhold information about convictions which for other purposes are "spent" under the provisions of the act.

An enhanced Discolsure and Barring Service (DBS) check (previously CRB) will be obtained prior to employment, you are therefore required to declare previous dealings with the police , and/or any convictions, past or future. Failure to do so at this sage will result in instant termination of you application.
Have you at any time received or had pending a court conviction or warning from the police?
I understand that because of the nature of the work that I am applying to be involved in, it will be a requirement that I agree to a DBS check at enhanced level, therefore I agree to this and will complete the necessary application forms.
Experience

Please detail aspect of care that you either have expereince of or would like to gain experience of.
I have experience of, or am interested in gaining experience of; Care of the elderly
I have experience of, or am interested in gaining experience of; Palliative care
I have experience of, or am interested in gaining experience of; Dementia care
I have experience of, or am interested in gaining experience of; Dementia care
I have experience of, or am interested in gaining experience of; Supporting people with physical disabilities
I have experience of, or am interested in gaining experience of; Supporting people with learning disabilities
I have experience of, or am interested in gaining experience of; Supporting children and families
Availability

Please indicate your expected availabilty. This is to enable us to accuratley assess your suitability to our curent needs.
I am available for Weekdays
I am available for Weekends
I am available for Early shifts (07:00 starts)
I am available for Late shifts (22:00 finishes)
Waking night shifts
Sleeping night shifts (22:00 - 07:00)
Live-in Care
Work History

(Please provide details of, at least, the last 5 years employment)
Name of employer
Employers Name
Email
example@example.com
Phone Number
Phone number
Address

Street Address

Street Address Line 2

City/TownCounty

Post Code
Position you held
Role/Position
Start Date

DayMonthYear
Date
Leaving Date

DayMonthYear
If still employed enter todays date
Reason for leaving
Reason
Please provide a short description of your role and responsibilities
Name of employer
Employers Name
Email
example@example.com
Phone Number
Phone number
Address

Street Address

Street Address Line 2

City/TownCounty

Post Code
Position you held
Role/Position
Start Date

DayMonthYear
Date
Leaving Date

DayMonthYear
If still employed enter todays date
Reason for leaving
Reason
Please provide a short description of your role and responsibilities
Name of employer
Employers Name
Email
example@example.com
Phone Number
Phone number
Address

Street Address

Street Address Line 2

City/TownCounty

Post Code
Position you held
Role/Position
Start Date

DayMonthYear
Date
Leaving Date

DayMonthYear
If still employed enter todays date
Reason for leaving
Reason
Please provide a short description of your role and responsibilities
Name of employer
Employers Name
Email
example@example.com
Phone Number
Phone number
Address

Street Address

Street Address Line 2

City/TownCounty

Post Code
Position you held
Role/Position
Start Date

DayMonthYear
Date
Leaving Date

DayMonthYear
If still employed enter todays date
Reason for leaving
Reason
Please provide a short description of your role and responsibilities
Please provide details of any gaps in your employment.
Reason for the gap, dates to and from.
Next of Kin
Name

First NameLast Name
Realtionship
Husband/Wife/Mother/Father etc.
Phone Number
Email
example@example.com
Applicant Declaration
Name

First NameLast Name
Signature
Date

DayMonthYear
Date
Add your CV

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Employment Application