Health Care Worker Application Form

Aging Grace Home Healthcare Career Application

The completion of this application form is part of stage one. This application will be reviewed, and a decision made as to whether to proceed to stage two, the interview, based on this information.
Please complete all sections on this form
Position Applying For
Title
Name

First NameLast Name
Data Protection Statement The personal information (data) collected on this form, are used only for the purpose of this employment. 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.

Employment History
Details of past employment starting with the most recent
Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home. Please use separate sheet if insufficient space is available.
Experience

Assistance with Interview and Assessment
Do you require us to make any special arrangements in order for you to participate in the recruitment process? For example, large print forms? Or additional time to complete forms?

YesNo
Any offer of employment may be made subject to a satisfactory medical report.

Identity Details
Are there any restriction to your residence in the US which might affect your right to take up employment in the US?

YesNo
If you are successful in the application, would you require a working permit prior to taking up employment

YesNo
References
You must provide references from your two most recent employers. Please provide an additional character referee. All will be contacted, therefore please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.
Add your references (starting with the current or most recent one)
Character reference
Professional reference
Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not and warnings and cautions in the space provided below.
Resume upload

Cancelof
SIGNATURE and DECLARATION IMPORTANT BEFORE SIGNING
I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my employment application. I understand that if I have provided any false information my application will be voided.
Date*

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Date
Signature*

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Education