Application Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty/Country

Postcode

National Insurance Number

Main Contact Number

Email Address

Are you aware of any issue which may prevent you from working in social care e.g. criminal convictions/charges?

Do you currently have the right to work in the UK?

What access to a mode of transport do you currently have (e.g. a car, motorbike, bicycle, public transport etc.)?

Do you have any care related qualifications?

If yes, please provide details here:

Rows	Date From	Date To	Qualification Gained and grrade/result
Qualification 1
Qualification 2
Qualification 3
Qualification 4

Employment History (Please complete your full work history here if you have had more roles please also utilise the next box)

Rows	Company	Position	Date From	Date To	Reason for Leaving
Most Recent/Current Position
Position 2
Position 3
Position 4
Position 5
Position 6

Work History Continued:

Tell us a bit about yourself and why you'd make a great member of our team.

Please Read and confirm the following:

The information provided on this form will be used in the recruitment and selection process and may be disclosed to all those relevant people.
It will also form the basis of your confidential personnel record if you are the successful candidate.
This application form will be destroyed after six months if you are unsuccessful.
We fully endorse and adhere to the Principles of the General Data Protection Regulations (GDPR) 2018.
I certify that, to the best of my knowledge, the information given in this form is accurate and without omission.
I understand and agree that this information may be stored and processed in accordance with the Data Protection Act 1998 and that HomeCare (Mellor) may take steps to verify the information I have provided, through references and checks of my qualifications.
I also confirm that I am physically and mentally fit to undertake the role for which I have applied and there are no health issues that would prevent me from carrying out the responsibilities of the post.
I confirm that I have read the Privacy notice for Job Applicants regarding information on GDPR.
I understand that any false information or failure to disclose relevant medical details, criminal convictions or prosecution pending may disqualify me from employment or render me liable to summary dismissal.

Date

Signature