Application form

Name*

First NameLast Name

Eligibility to work in the UK*

Address*

House number / building name

Street Address

City

Post Code

Mobile Phone number*

Email*

National Insurance Number

Next of Kin / Emergency contact*

	Please complete
Name
Relationship to you
Telephone number

Transport: - Please tell us how you will travel for work*

I have my own transport (including valid licence, business insurance, Tax & MOT)I use public transport

Language (Spoken)*

	Fluent	Fair	Limited
English

Language (Written)*

	Fluent	Fair	Limited
English

Other languages (fluent in spoken & written)

Education:

	School / College	From / To	Qualifications
School 1
School 2
School 3

Training:

	Training provider	From / To	Qualifications
School 1
School 2
School 3

Skills & Experience: - Tell us why you are applying for this job. Please refer to the Job Description. You should also show how you meet each requirement by providing details of your experience, skills and knowledge gained in employment, voluntary work or elsewhere

References: Last or most recent employer (we will use this information to obtain a reference)*

	Please complete
Company Name
Line Manager
Address
Telephone number
Emal address
Dates employed - from / to

Reference 1: (we will use this information to obtain a reference)*

	Please complete
Referree name
Address
Telephone number
Emal address
Dates - from / to

Personal Reference: (we will use this information to obtain a reference)*

	Please complete
Referee name
Relationship to you (must not be family member)
Address
Telephone number
Emal address
How long known

Position Applied for:

Care WorkerField Care SupervisorCare Coordinator

Which area can you work in? Please tick appropriate box:

LeedsWakefieldBradford

Previous employment - Most recent first. Include any voluntary work (we will use this information to obtain a reference)*

	Company name	Dates from / To	Line manager contact details	Reason for leaving
1
2
3
4
5
6
7
8
9
10

Gaps in employment - Please detail the reason for any gaps in your employment history

CRIMINAL OFFENCES & REHABILITATION OF OFFENDERS

Your answer to the following question should include any ‘spent’ convictions, conditional discharges, bind-overs or cautions. The ‘Company’ actively promotes equality of opportunity for all as stated in its Equal Opportunities policy, which can be found in the staff handbook or at your local office. Making a false statement or any attempt to conceal information regarding this declaration will lead to the rejection of your application for employment with this company. Any details provided will be treated in the strictest confidence and will not automatically exclude anyone from being considered for any vacancy

Have you ever been convicted of a criminal offence or received a Police Conditional discharge, bind-over, caution, warning or reprimand?*

Have you ever been issued with a Penalty Notice for Disorder?*

If you answered YES to the above, please provide details and dates of the offence(s) below

Working hours preference*

Pre-booked holidays - please let us know dates of any pre-booked holiday

Availability: (tick all that apply) - Please note – As we operate over 7 days, you are required to work alternate weekends*

	Mon	Tues	Wed	Thu	Fri	Sat	Sun
Breakfast & Lunch 7am - 2pm
Tea & Bedtime 4pm - 10pm

EU Directive - 48 hour Opt-out - Are you willing to work more that 48 hours in any 7-day week?*

Declaration

Data protection - The Data Protection Act 1998 requires that any staff handling personal data on others must follow certain principles in relation to the data that they hold. Individuals have rights of access to data that is held on them and rights to claim for damages if various offences occur. This covers manual as well as computerised records. If you are unsuccessful in this application, we will keep this form on file for 6 months should you wish to be considered for other vacancies within the organisation

Rehabilitation of Offenders Act 1974 - The Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Amendment) Order 1986 provides that people in employment which is concerned with the provision of care or who carry out their duties wholly or partly on the premises where such provision takes place, are obliged to disclose any convictions which would otherwise be spent. The Regulations provide that people in employment which is concerned with the provision of care or who carry out their duties wholly or partly on the premises where such provision takes place are obliged to disclose any criminal convictions, conditional discharges, bind-overs or cautions that they have been subject to at any time in the past.

Declaration - I confirm that all the information given is true and I understand that any false or misleading information may result in my removal from our register of applicants. I consent to the processing of sensitive personal data.

I confirm the above information is correct*

Date*

Date

Application Form