Application Form

Application Form
HEALTH CARE ASSISTANT APPLICATION FORM

Please complete this form in CAPITAL LETTERS and complete all sections
Position For
Name and Surname
Data Protection Statement
The personal information (data) collected on this form, and on the attachments, (which include the collection of sensitive personal data) are collected for recruitment, personnel administration (for new employees), and monitoring. Unless you direct otherwise (for example in a situation where you would like this Application kept on file for future vacancies) the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6 months. It is the policy of the Agency to protect and keep secure, all personal data collected. All personal data is processed for recruitment, and, in the case of successful Applicants, for the satisfactory administration of their
employment, and no other purpose.
Equality of Opportunity Statement
The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.

1.Personal Details
Title
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Mobile)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Home)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Work)
Please enter a valid phone number.Format: (000) 000-0000.
May we contact you at work?
Email
example@example.com
Nationality
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
National Insurance Number
Next of Kin to be notified in case of emergency:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Mobile)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Home)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Work)
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you

2. Formal Education and Qualifications
Name of School/College/University

Location
Date Attended (From)

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date Attended (To)

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Course of Study/Qualification(s) gained
Grade

3. Employment History

Please provide details of your last employment. Please include reasons for gaps.
Name of Employer

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates of Employment (From)

MonthDayYear
2 digit month, 2 digit day, 4 digit year
To

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Position Held
Summary of Duties and Responsibilities
Reasons for leaving
Last salary or wage

6. Additional Information

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 provide details of any relatives employed by the Agency and their relationship to you.
Additional Information

7. References

References are normally taken up for candidates selected for interview. Give details of the names/addresses of two work-related Referees. One of the Referees should be your current employer, or if presently unemployed or self-employed, your last employer
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position
Relationship to you
May we contact the above person now?
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Position
- Relationship to you
- May we contact the above person now?

8. Confidentiality declaration

Registration implies acceptance of our code of confidentiality.In the course of your duties, you may have access to confidential information about your clients. On no account must information relating to identifiable clients be divulged to anyone other than the manager of the agency. You should not disclose ANY information to your family, friends or neighbours.If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER.Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register.I have read and understand the above and I agree to abide by the contents therein.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

11. Rehabilitation of Offenders Act
As a general rule, no one needs to answer questions about spent convictions. However, this general rule does not apply to specified professions, employment, and occupations. Under the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to:

a)any employment or other work that is concerned with the provision of health services and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to persons in receipt of such services in the course of his normal duties, or

b)any employment or other work which is concerned with the provision of care services to vulnerable adults and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to vulnerable adults in receipt of such services in the course of his normal duties. One or both of the above apply to work with the Agency and cover all occupations. You are therefore requested to provide details of all convictions, including those which would otherwise be considered as “spent”. All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected.
Records will be checked via the Criminal Records Bureau procedures
Do you have convictions
If Yes, Please give details.
Asylum and Immigration Act 1996

Under Section 8 of the Asylum and Immigration Act 1996 it is a criminal offence to employ a person aged 16 or over who is subject to immigration control unless:•That person has current and valid permission to be in the United Kingdom and that permission does not prevent him or her from taking the job in question; or• The person comes into a category specified by the Home Secretary where such employment is allowed. Any employment offered will be subject to the successful applicant producing appropriate evidence that the Asylum and Immigration Act is not being contravened.
Are you eligible to work in the UK?
Personal Declaration

I declare that to the best of my knowledge the above information, and that submitted in any accompanying documents, is correct, and
-I permit any inquiries that need to be made to confirm such matters as qualifications.
experience and dates of employment, and for the release by other people or organisations of such information as may be necessary for that purpose.

-I permit the processing of the personal data contained in this form for employment purposes

-I understand that any false or misleading information could result in my dismissal.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Application Form

HEALTH CARE ASSISTANT APPLICATION FORM

1.Personal Details

2. Formal Education and Qualifications

3. Employment History

4. General information

5. Preference regarding work

6. Additional Information

7. References

8. Confidentiality declaration

11. Rehabilitation of Offenders Act

Asylum and Immigration Act 1996

Personal Declaration