A1) Application Form

Application Form

Healthcare Assistant
The Local Care Company is committed to safeguarding and promoting the welfare of adults at risk, and expects all our staff to share these values. We are also committed to treating all applicants equally and fairly based on their skills, experience, and ability to fulfil the duties required of the role applied for. This is regardless of any protected characteristics (ethnicity, gender or gender reassignment, religion or belief, sexual orientation, physical/mental disability, age, pregnancy or maternity, marriage, or civil partnership).

Applicants must share with us all the relevant information that we have requested in this application form, but we would like to reassure applicants that any information provided will be treated in the strictest confidence in a fair and open manner. Suitable applicants will not be refused employment because of offences or conduct which are no longer relevant, and do not place them at, or make them a risk in the role for which they are applying. We will ensure that all our recruitment and selection practices reflect this commitment.

Personal Information
Full Name*

Title (Mr, Mrs, etc)First NameSurname
Date Of Birth *

MonthDayYear
National Insurance Number

Contact Details
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

Town/CityCounty

Post code

About You
How many hours per week would you like to work ?*
Are you a driver with access to car?*

YesNo
Where did you hear about the The Local Care Company ?*
If you were referred by a current TLC employee, please write their name here.
Do you have experience working in Healthcare ?*

YesNo
Next of Kin Name *
Next of Kin Telephone*
Other than English, do you speak any languages fluently ?

Employment History
Are you currently employed?*

YesNo

If yes, please give details below.
Company Name
Employed from

MonthDayYear
Address of employer

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Job Title
Are you required to work a notice period with your current employer ?
What is your reason for leaving this employment ?

Employment History

Please give details of your most recent 3 employments.

Employer 1
Name of employer
Employed from

MonthDayYear
Employed to

MonthDayYear
Job title and responsibilities
Reason For Leaving

Employment History

Please give details of your last 3 employments.

Employer 2
Name of employer
Employed from

MonthDayYear
Employed to

MonthDayYear
Job title and responsibilities
Reason For Leaving

Employment History

Please give details of your last 3 employments.

Employer 3
Name of employer
Employed from

MonthDayYear
Employed to

MonthDayYear
Job title and responsibilities
Reason For Leaving

Education
There are no requirements in terms of education or experience for this role, however please use the form below to detail any qualifications you hold.

Courses & Certificates Relative To Role
Please provide details of any courses or certificates that you feel are relative to the role.
If you have digital copies of any of your certificates please upload them here.

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Gaps In Training Or Employment History
Do you have any significant gaps in your employment/training history ?*
If yes, please give an explanation below.

References
Please provide contact details for at least two referees who are able to comment on your suitability for the job applied for. You are responsible for providing accurate contact details so that referees can be contacted.

The first referee MUST be your current or most recent employer (or your course tutor if you are currently in, or have just left, full time education).

Professional references will not be accepted from work colleagues who are not authorised to provide professional references in an official capacity on behalf of the organisation, or from people writing solely in the capacity of friends, or from relatives.

Referee 1
Name*

First NameLast Name
Company / Institution*
Job Role*
Phone Number*
Email*
If you have a digital copy of your reference, please upload it here.

Cancelof

Referee 2
Name*

First NameLast Name
Company / Institution*
Job Role*
Phone Number*
Email*
If you have a digital copy of your reference, please upload it here.

Cancelof

References
The Local Care Company will seek references on successful candidates, and will approach previous employers for information to verify particular experience or qualifications. If you are currently working with adults at risk and or children, your current employer will be asked about disciplinary offences relating to adults at risk and/children (including any conduct related to safeguarding concerns which the penalty is ‘time expired’), and whether you have been the subject of any safeguarding related investigations or concerns, and if so, the outcome of any enquiry or disciplinary procedure including any referrals to Disclosure and Barring Service (DBS), other professional bodies or the police.

If you are successful at interview, any offer of employment will be subject to receipt of two satisfactory references and any additional pre-employment checks.

Right To Work
Do you require permission from the Home Office to work in the UK ?*

YesNo

If yes, please complete this section.
What type of VISA do you have ?
When does your VISA expire ?

MonthDayYear
Please upload a digital copy of your Passport, VISA & BRP.

Cancelof

Criminal Record Checks
This post involves working in Regulated Activity under the Safeguarding Vulnerable Groups Act 2006 and is subject to an enhanced DBS with barred list check (i.e. adults, children or both). It is a criminal offence to apply for or accept a position working with adults at risk and/children if you have been barred from engaging in regulated activity with the relevant group (i.e. adults, children or both).

Criminal Record Checks
Are you included in the list of people barred from working with adults or children maintained by the Disclosure and Barring Service (DBS) ?*

YesNo
If you are not currently barred from working with adults at risk and/children, have you been referred to the Disclosure and Barring Service (DBS) for consideration to be added to one of the barred lists?*

YesNo

Conduct Declaration
Have you ever been dismissed for misconduct from any employment, or other position previously held by you ?*

YesNo

If yes, please give details.
Please give details of the dismissal(s).

Conduct Declaration
Have you ever been subject to any disciplinary sanctions in relation to your conduct at the time of dismissal/leaving your employment, or other position held by you ?*

YesNo

If yes, please give details.

Reasonable Adjustments
Please be aware when applying for the role of a Homecare Assistant, that this is a physically and mentally challenging position and may require you to operate moving and handling equipment.

You will need to make us aware of any reasonable adjustments that we can make in order for you to meet the requirements of the role offered. This will enable us to carry out a risk assessment (if necessary). Please give details below:

If applicable, please give details below.

Supporting Statement
Please write a short statement explaining why you feel you are a good candidate for the role below, consider your personal qualities, behaviors, values & experience.

C.V
Please upload a digital copy of your C.V.

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Declarations
Failure to provide accurate and truthful information is considered a serious matter. If it becomes apparent that inaccurate or incomplete information has been provided, we will need to establish why. Any finding of serious misdirection or intent to deceive will result in an application being disqualified or, if appointed, disciplinary action being taken and/or dismissal.
All information on this form will be treated in strictest confidence and used to process your application for employment. If you are appointed, this application will form the basis of your personal file and information on this may be held in an electronic database. If your application is unsuccessful your details will be kept for a period of 3 months and then destroyed.
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Application Form

Personal Information

Contact Details

About You

Employment History

Employment History

Employment History

Employment History

Education

Courses & Certificates Relative To Role

Gaps In Training Or Employment History

References

Referee 1

Referee 2

References

Right To Work

Criminal Record Checks

Criminal Record Checks

Conduct Declaration

Conduct Declaration

Reasonable Adjustments

Supporting Statement

C.V

Declarations