CareBrix Carer Application Form

APPLICATION FORM
Thank you for your interest in working with us! Please take your time to carefully complete each section of this form. If you need more time, you can save your progress and return later.

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Position Details
Position Applied for:*
Where Did You Hear About This Role?*
Do you require us to make any special arrangements in order for you to participate in the recruitment process? For example, additional time to complete forms.*

YesNo
Please provide details*

Personal Information
Full Name*

First NameLast Name
Do you have any previous surnames?*

YesNo
Previous surname(s)
DOB*

DayMonthYear
Date
Gender*
Contact Number*
Email*
example@example.com
Please upload x2 Proof of ID*

e.g. Passport, UK Driving Licence, BRP, National ID card, or Home Office Travel Document
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Do you have a full valid drivers license?

YesNo
Do you have your own transport? (E.g car)

YesNo
Please upload proof of your vehicle insurance

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Next of Kin/Emergency Contact*
Enter their name, address, contact number and email.
GP details*
Enter their name, address and contact number

Work Eligibility
NI Number*
Right to-work Sharecode*
Kindly generate a new right to work sharecode and input it in the field provided above. If your nationality is British, please type 'British'.
Are there any restrictions on your right to work in the UK?*

YesNo
Please provide details*
Please upload Proof of NI*

P60, payslip, HMRC or DWP letter, NI card, benefits letter, tax return.
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Do you have a UTR Number? *

YesNo
Have you applied for an UTR Number?*

YesNo
Upload Proof of UTR Number*

HMRC letter showing your UTR number, official tax return, or HMRC online account screenshot.
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Upload Proof of UTR Application*

HMRC letter showing your UTR number, official tax return, or HMRC online account screenshot.
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Address History - Last 5 Years
Current Address*

Door Number / Street Name

Street Address Line 2

CityState / Province

Postal / Zip Code
When did you move to this address?*

DayMonthYear
Previous Address *

Door Number / Street Name

Street Address Line 2

CityState / Province

Postal / Zip Code
When did you move to this address? *

DayMonthYear
Todays Date

DayMonthYear
Date
Days at Current Address
Does your current and previous address history cover the last 5 years till date?*

YesNo
Additional previous addresses.*
Include Non-UK Addresses
Upload Proof of Address - Must be within the last 3 months. *

e.g. UK Driving Licence, Utility Bill, Bank Statement, Council Tax
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Education History
Please list all relevant qualifications and training you have completed in the tables below. Add as many rows as needed to include everything.
Education History - (Evidence will be required)
Training & Certificates (Evidence will be required)*
Upload Proof of Required Training *

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Employment History
Please provide a full and accurate record of your employment history starting from the age of 18 till date. Clearly explain any gaps over 4 weeks in your employment history. Add as many rows as needed to include everything.

This information is required to meet CQC Safer Recruitment standards.
Employment History*
Does your employment history cover the period from age 18 years old till date, with all gaps in employment clearly explained?*

YesNo
Additional Employment History/Gaps in Employment*
Please upload your most up-to-date CV*

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Professional & Character References
Please provide two references, one of which must be from your most recent employer, along with one character reference. We will contact all referees, so please make sure they are aware you’ve listed them. If you’re unable to provide any of these, get in touch with us to discuss alternatives.
Current/Most Recent Employer *
2nd Professional Ref*
Character Reference*

Criminal Record
Workers of the agency are subjected to the Health and Social Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether processed with or not and warnings and cautions. You will not be eligible for work in a care setting if you are on the DBS Register(s).
Have you ever received a criminal conviction, charge, warning, or caution - whether or not you was prosecuted or it was spent?*

YesNo
Please provide details*
If you have no criminal convictions please type None.
What is your DBS Status?*

Valid DBS (within 12 months)On Update ServiceNo valid DBS
Please upload a valid Enhanced DBS Certificate. We must have the original green certificate*

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Signature & Declaration - Read Before Signing
I declare to the best of my knowledge and believe the information given to me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.

I understand that I cannot be offered a post until a satisfactory response has been received with respect to my DBS register status, and that I should subsequently should be offered a post, that offer will be a subject to receipt of two satisfactory references, one of which must be from my previous employer, and that conformation of the employment will be subject to a satisfactory criminal record check from the DBS.

I understand that the satisfactory response is received from the DSB, and the employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. By my signature I authorise the organisation to request a DBS register check and a criminal records check from the DSB, on initial employment and at any time during my employment thereafter, I undertake to inform my employer immediately if my DBS register status changes.
Consent & Data Agreement
I consent to CareBrix Solutions Ltd processing my personal data, including sharing relevant information with third parties for employment, recruitment, and compliance purposes.
I agree to receive communication via email, phone, or text in relation to job opportunities, onboarding, training, and updates.
I understand that my data will be stored securely and processed in accordance with CareBrix Solutions Ltd’s Privacy Policy. I understand I can withdraw my consent at any time by contacting info@carebrix.com
Signature*

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APPLICATION FORM