APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

Form UHS-0172
1. Application Form
Position applied for:

Health Care AssistantSenior Support Staff
Enter preferred start date:

MonthDayYear
Date
2.Preferred Availability

Must work alternate weekends.
Prepared to Work

Full timePart timeBank Hours
Availability

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
3. Personal Details
Name

First nameLast name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
What type of driving license do you hold?

Full UKInternationalUK ProvisionalNone
Do you own a car?

YesNo
Do you have any current endorsements?

YesNo
If yes give details
4. Languages
Do you speak or read another language? (including sign, makaton)

YesNo
If yes give details
What level of fluency?
5. Education and Training

Please fill in all below details:
Secondary Education & Further Education:
Training Qualifications (eg: NVQ/QCF in Health and Social Care)
Do you have previous experience in Domiciliary Care?

YesNo
If yes how many years?
Provide details of previous role(s)
Do you hold a current DBS?

YesNo
6. Employment

Please supply full employment history (most recent to leaving education)
Present/last employer
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Address
Job title
Duties/responsibilities
Reason for leaving
Other employer
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Address
Duties/responsibilities
Reason for leaving
Other employer
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Address
Duties/responsibilities
Reason for leaving
Other employer
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Address
Duties/responsibilities
Reason for leaving
Gaps in employment (use this section to confirm in detail the reason(s) including dates to and from for any gaps in your employment)
7. General
Interests/hobbies (give details of pastimes, sports, etc)
Do you have any convictions, cautions reprimands or final warnings that are not "protected" as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)?

YesNo
The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are "protected" and are not subject to disclosure to employers, and cannot be taken into account. Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and Barring Service Website. (Declaration subject to the Rehabilitation of Offenders Act 1974). If yes, give details
8. Permission to Work in the UK
Are there any restrictions to your residence in the UK that might affect your right to take up employment in the UK?

YesNo
If you are looking for additional hours please state your sponsorship company name and full address.
9. Community/Volunteer Experience

Community Volunteer Experience

	Name and Address of organisation	Position	Duties
1
2
3
4

10. References

Please supply two work references. One reference must be your current/last employer.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / County

Postal / Zip Code
Organisation
Job title
Phone Number
Email
example@example.com
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / County

Postal / Zip Code
Organisation
Job title
Phone Number
Email
example@example.com
11. Additional Personal Details
Additional Personal Details

Applicants are requested to tick the relevant boxes below to enable the organisation to monitor its equal opportunity policy. Monitoring is recommended by the Codes of Practice for the elimination of racial discrimination and for the elimination of discrimination on the grounds of sex and marital status. This information is used for no other purpose and will be treated as confidential.
Please select applicable

White BritishWhite IrishWhite otherBlack/Black British - AfricanBlack/Black British - CarribeanBlack/Black British - Other Type option 6Mixed - White and Black AfricanMixed - White and Black CarribeanMixed - White and AsianMixed - OtherAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiOther Asian BackgroundChineseArabOther
MaleFemale
Recruitment Policy
It is Unicorn Healthcare Services' policy to employ the best qualified personnel and provide equal opportunity for the advancement of employees including promotion and training and not to discriminate against any person because of race, colour, ethnic origin, national origin, sex, sexual orientation, religion or belief, pregnancy, trans-gender status, marital or civil partnership status, age or disability.
I authorise the organisation to obtain references to support this application once an offer has been made and accepted and release the organisation and referees from any liability caused by giving and receiving information.
I confirm that the information given on this form is, to the best of my knowledge, true and complete. Any false statement will be sufficient cause for rejection or, if employed, dismissal.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

APPLICATION FOR EMPLOYMENT

1. Application Form

2.Preferred Availability

3. Personal Details

4. Languages

5. Education and Training

6. Employment

7. General

8. Permission to Work in the UK

9. Community/Volunteer Experience

10. References

11. Additional Personal Details

Recruitment Policy