Job Application Form - Support Worker

Job Application Form - Support Worker
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityCounty

Postcode
Date of birth:

MonthDayYear
Date
Phone number:
Email:
example@example.com
Driving Licence Information
Do you have a full UK driving licence?

YESNO
Do you have any endorsements on your driving licence?

YESNO
If YES, please provide further details here:
Contract/Hours
What type of contract would you ideally like to have?

Part-time ContractFull-time ContractBank Contract (you would be able to put yourself forward for open shifts according to your availability, hours are not guaranteed)
It part-time, how many hours per week would you ideally like to work?
We have properties in Strood, Chatham and Gillingham. Please select the boxes below to confirm that you can cover these areas and there are no restrictions:

StroodChathamGillingham
We work on a 2-week shift pattern and contracted staff should be available to work proportionate hours every other weekend. Select the boxes below to confirm the sorts of days and times you are available to work:

Weekdays 9am-4pmWeekdays 4pm-10pmWeekdays overnightWeekends 9am-4pmWeekends 4pm-10pmWeekends overnight
Are there any particular days/times you cannot work due to other commitments? Or are there any restrictions or covenants which may restrict your working hours (eg, visa restrictions)?
Do you need a work permit to take up employment in the UK?

YESNO
General Information
How did you find out about the vacancy?
Have you ever worked/applied for employment with Anchor Support Services Ltd before?

YESNO
If YES, please provide further details here:
Have you any convictions (other than spent convictions under the Rehabilitation of Offenders Act 1974)?

YESNO
If YES, please provide further details here:
Education & Training
Please provide details of all schools and further education attended since age 11 including dates to and from, examination results and qualifications gained:
Please provide details of any job related training courses you have completed including the dates:
Please list languages spoken and the level of competence:
Employment History
Are you currently employed?

YESNO
Name and address of your current employer:
What is the nature of the business and what is your role and responsibilities there? What is your reason for leaving?
Length of service:
How much notice do you need to give your current employer to terminate your employment?
Please provide details of all other employment history and explain any gaps in your employment (for example, illness or maternity leave):
We require two references. At least one should be a professional or academic reference and one can be a character/personal reference. References will only be requested if your application is successful and you accept your offer of employment.
REFERENCE 1 - please provide the name, address, telephone number and email for your first reference:
REFERENCE 2 - please provide the name, address, telephone number and email for your second reference:
Medical Information
Data Protection Notice: The company requires certain information prior to you commencing employment to ensure you will be able to perform the requirements of the job and give reliable service, and to ensure compliance with relevant Health and Safety regulations. The information is also required in order to establish whether any reasonable adjustments may need to be made to assist you in performing your duties, in accordance with the Disability Discrimination Act 1995. The information you provide will be treated in the strictest confidence, and used for the purposes detailed above and in compliance with the Data Protection Act 1998.
If offered employment, you will be required to complete a full Pre-Employment Medical Questionnaire and depending on the information declared, you may be required to undergo a medical examiniation. Is this okay?

YESNO
Do you suffer from any allergy, injury, illness or medical condition that might affect your ability to perform your duties?

YESNO
If YES, please provide further details here:
Equal Opportunities
Gender:

MALEFEMALE
Ethnic origin:

White BritishWhite IrishAny other White backgroundAsian, Asian British Indian, Asian Pakistani, any other Asian backgroundBlack, Black British Caribbean, Black British African, any other Black backgroundChineseMixed White and Asian/Black African/Back Caribbean, any other mixed backgroundOther ethnic group
Do you consider yourself to have a disability as defined by the Disability Discrimination Act 1995 which defines disability as "a physical or mental impairment which has a substantial and long-term adverse effect on a person's ability to carry out their normal day-to-day activities"?

YESNO
Declaration
I declare that the information given in this application is complete and accurate. I understand that any false information or deliberate omissions will disqualify me from employment or may render me liable to summary dismissal. I understand these details will be held in confidence by the Company, for the purposes of assessing this application, ongoing personnel administration and payroll administration (where applicable) in compliance with the Data Protection Act 1998.
Signature:

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