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
Walk-InEmployee ReferralFacebookTwitterInstagramIndeedMonsterTotal JobsJob CentreOther (please specify)
Others:
Please provide details
YesNo
If YES, but there are conditions, please specify what these are:
Please provide details
YesNo
YesNo
YesNo
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.
YesNo
YesNo
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.
YesNoOccasionally
Both days, Every WeekendOne day, Every WeekendBoth days, Every Second Weekend
YesNoOccasionally
YesNoOccasionally
YesNoOccasionally
YesNoOccasionally
YesNoOccasionally
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*

Clear
Date*

DayMonthYear
Date
Add your CV

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Should be Empty:

Employment Application