Job Application Form - Support Worker

Job Application Form - Support Worker
Name:

First NameLast Name
If you have ever been known by any other names, please state the names and the reason for the change(s):
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
If YES, do you have a vehicle to use for work?

YESNO
If YES, 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 overnight (sleep-ins)Weekdays overnight (wake nights)Weekends 9am-4pmWeekends 4pm-10pmWeekends overnight (sleep-ins)Weekends overnight (wake nights)
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?
What personal qualities, values and experience do have that you believe are relevant to your suitability for the role and how do you meet the person specification set out in Anchor's candidate pack (available on our website)?
Are you related to and/or do you have a close relationship with anyone currently employed by Anchor?
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:
Have you ever been subject to any disciplinary and/or safeguarding concerns/investigations relating to vulnerable adults (including any conduct related to safeguarding concerns which the penalty is ‘time expired’)?

YESNO
If YES, what was the outcome of any investigation or disciplinary procedure, including referrals to DBS, other professional bodies or the police?
Education & Training
Have you completed the Care Certificate?

YESNNO
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, References & Checks
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 your full employment history in chronological order, including any work experience/voluntary positions, and time spent completing further adult education after leaving education, 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.

Professional references will not be accepted from relatives, 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.

If you are currently working with vulnerable adults, your current employer will be asked about disciplinary/safeguarding concerns/investigations (including any conduct related to safeguarding concerns which the penalty is 'time expired'), and the outcome of any such concerns/investigations.

References will only be requested if your application is successful and you accept your offer of employment. We may also approach previous employers for information to verify particular experience or qualifications.

You are responsible for providing accurate contact details, any errors in the information providing/missing information, may affect your application and/or employment is your application is successful.
REFERENCE 1 - please provide the name, address, telephone number and email for your first reference which should be your current/most recent employer. If you have never been employed, reference 1 should still be a professional person, for example, your teacher/tutor:
REFERENCE 2 - please provide the name, address, telephone number and email for your second reference:
Do you hold a current/valid DBS certificate dated within the last 12 months and/or are you subscribed to the DSB Update Service?

YESNO
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.

I understand that is is a criminal offence for people who are barred from working in Regulated Activity (under the Safeguarding and Vulnerable Groups Act 2006) to apply for roles that require them to work unsupervised with that particular group (ie, adults at risk, children or both). I declare I am not on the list of those barred from working with vulnerable adults or subject to sanctions imposed by a regulatory body.
Signature:
Should be Empty: