Employment Application Form

Employment Application Form

Please fill in the application form in full
Position Applied for:
Personal Details
Title
Surname
Forname(s)
Previous Names
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your email address (if any)
example@example.com
Home Telephone

Country CodePhone Number
Mobile Telephone

Country codePhone Number
Work/Other Telephone

Country CodePhone Number
Nationality
Country of birth
Work Permit Number (If Applicable)
National Insurance Number
Do you hold a current UK Driving Licence

YesNo
Do you have a car to use?

YesNo
Employment History(Most recent first)

Please give a full and continuous employment history since leaving full time education explaining any gaps or breaks.

	Start Date	Finish Date	Position Held	Employer Name and Address	Reason for leaving
1
2
3
4

Professional Qualifications

Please enter in the sections below only qualifications relevant to the position for which you are applying.
NMC

NMC PIN NumberPart Register
Expiry Date

	Qualifications	Date Obtained	Place of Training
1
2
3
4

Educational Qualifications

	Name & Address of School	Year Attended	Results/Grade obtained
1
2
3
4

Do you have any formal training in care?

	Training done	Date obtained	Expiry Date
1
2
3
4

Supporting Information
Please give details of any additional information which you would like to include in support of your application. Such information, for example, may include skills and/or achievements which you think may be of interest, and/or a summary of why you believe that you have the qualities we are looking for. ( Please continue on additional sheets if necessary).
References

Please supply the details of at least two referees of which, one must be your current or most recent employer. References will be sought upon successful interview.
Reference 1
Full Name
Profession/ Position
Finishing Date

MonthDayYear
Date
Start Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2
Full Name
Profession/ Position
Phone Number
Please enter a valid phone number.
Start Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Finishing Date

MonthDayYear
Date
Reference 3
Full Name
Profession/ Position
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date

MonthDayYear
Date
Finishing Date

MonthDayYear
Date
If your application were successful, when would you be able to commence work?

MonthDayYear
Date
If applying for this position as a secondary income, responsibility is placed on you the applicant to seek authorisation where necessary
Rehabilitation of Offenders Act 1974

By virtue of there habilitation of offenders act 1974 ( Exceptions order 1975, the provisions of section 4.2 of the rehabilitation of offenders Act 1974 do not apply to any employment which is concerned with provision of health services and which is of such a kind as to enable the holder to have access to persons on receipt of such services in the course of his normal duties. Your answer to the following questions should include any ‘spent’ convictions.
Have you ever been convicted of a criminal offence?

YesNo
If ye please provide details including dates?
I have answered the above questions honestly and fully and that I am not aware of any physical or mental disability, which may affect my working capacity. I realise that any false or incomplete statement on my part will render me liable to disciplinary action or dismissal. I also understand that my details will be submitted for a check by the Disclosure Bureau Service.
I agree to comply with the current Health and Safety at Work Act.*

YesNo
It is a condition of employment that you work flexibly in accordance with the requirements of the Company. Accordingly, if accepted and employed you acknowledge that there may be periods when no work is available, and the Company has no obligation to provide an employee with any work or to provide with any minimum number of hours in any day of the week.
Signature

Powered by Jotform SignClear
Please detail any further information you wish to put forward in support of your application.
I declare that the above information is true. I understand that any job offers made on the basis of untrue or misleading information may be withdrawn or my employment terminated*

YesNo
Equal opportunities
POLICY

The company MEE@Home Healthcare LTD is opposed to discrimination on any grounds. In particular, we oppose discrimination on the grounds of race, religion, ethnic origin, sex, sexuality, marital status, disability or age. MEE@Home Healthcare LTD is committed to ensuring that ability and potential for the job are criteria used for all staff selection.

Monitoring

The company has adopted the provision contained it the code of Practice published by the Equal Opportunities Commission for Racial Equality and the Code of Practice published by the Equal Opportunities Commission that employers should regularly monitor the effects of selection divisions to assess whether equal opportunities is being achieved. For this purpose, you are asked to complete and return this form with application form. This information is for statistical reasons only and will be treated as confidential.
Applicant Full Name
Post Applied For
Location
Sex

MaleFemale
My Marital Status is

SingleMarriedOther
Ethnic Group
Ethnic Origin “ refers to a racial group defined by the Race Relations act 1976 as a group of persons described by reference to colour, race, nationality or ethnic or national origin.
White

BritishIrishOther
Mixed

White and Black CaribbeanWhite and Black AfricanWhite and AsianOther
Asian or Asian British

IndianPakistanBangladeshOther
Chinese or Other Ethnic Grouo

ChineseOther
Black or Black British

CaribbeanAfricanOther
Disabilities
Do you have any disabilities?

YesNo
Should be Empty:

Employment Application Form

Personal Details

Employment History(Most recent first)

Professional Qualifications

Supporting Information

References

Reference 1

Reference 2

Reference 3

Rehabilitation of Offenders Act 1974

Equal opportunities

Ethnic Group

Disabilities