Application Form

Thank you for your interest in working with us! Please take your time to carefully complete each section of this form.

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Role Applied for*

Profile Picture*

Please upload a picture we can use for your profile e.g selfie or passport picture

Full Name*

As it appears on your passport

Date of Birth*

Date

Country of Birth / Nationality

Gender*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Bank Account Details *

Name on account

Sort Code

Account Number

Is this Bank Account in your name?*

YesNo

Do you give consent for your wages to be paid into the account provided on your behalf?*

I consent

Address*

Have you lived at this address for 5 years or more?*

YesNo

Address 2*

Have you lived at this address for 5 years or more?*

YesNo

Please list your address history for the last 5 years below*

Next of Kin Details*

Do you consent for us to contact this person in case of emergency?*

Yes

NI Number

Are you self-employed with a UTR number?*

YesNoNeed to register

UTR Number

Do you have self-employed carer insurance?*

YesNoNeed to arrange

Diver / Non Driver

DriverNon Driver

Do you hold a valid driving licence?

YesNo

Own Transport?

YesNo

Do you require a share code to prove your Right-to-Work?*

YesNo

Sharecode*

Right-to-Work Status*

Please describe your right to work status.

Are there any restrictions on your right to work?*

YesNo

Provide details

Highest qualification in Health/Social care

Training Provider

Year Completed

Do you have mandatory training certificates?*

YesIn ProgressNo

NMC Pin (if applicable)

How long have you worked in healthcare in the United Kingdom?*

Have you worked as a live-in carer before?*

YesNo

Are you willing to travel for placements?*

YesNo

Employment History

Please provide your full employment, education, or activity history from age 18 to present. There must be no gaps over 4 weeks. If you had any period without work or study (e.g., travelling, job seeking, maternity, illness), please explain this.

Current/Most Recent Employer (UK Only)*

Have you worked here since you were 18?*

YesNo

Warning!

Your application will be delayed if the history is incomplete or has gaps over 4 weeks.

Employer 2

Have you worked here since you were 18?

YesNo

Warning!

Your application will be delayed if the history is incomplete or has gaps over 4 weeks.

Employer 3

Have you worked here since you were 18?

YesNo

Warning!

Your application will be delayed if the history is incomplete or has gaps over 4 weeks.

Please use this section to add any additional employment history and explain any gaps in your employment history (Gaps longer than 4 weeks)*

e.g Education, Relocation, Motherhood/Fatherhood etc...

References Section

Please provide 3 references (2 professional & 1 character)

Reference 1 Email - (Professional - Most Recent Employer)*

example@example.com

Reference 1 Info*

Reference 2 Email - (Professional)*

example@example.com

Reference 2 Info*

Reference 3 Email - (Character)

example@example.com

Reference 3 Info

Do you consent to us contacting the references you have provided?*

Yes

GP Details*

Do you have any medical conditions that could affect your role?*

YesNo

Provide details

Do you require any adjustments for interview or work?*

YesNo

Provide details

What is your DBS Status?*

On Update ServiceValid DBS (within 12 months)No Valid DBS

If you do not currently have a DBS, or if your existing certificate has expired, we work with a third-party organisation, Due Diligence Checking Ltd (DDC), to provide quick, reliable, and professional online DBS checks.

DDC will contact you directly to process the DBS application and take payment. Please note there is a charge for this service.

Workforce Type*

Have you ever been barred from working with vulnerable adults or children?*

YesNo

Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.*

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.

I consent to CareBrix Solutions Ltd processing my personal data, including sharing relevant information with third parties for employment, recruitment, and compliance purposes.*

Yes

I agree to receive communication via email, phone, or text in relation to job opportunities, onboarding, training, and updates.*

Yes

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*

Yes

Signature*

Application Form

SECTION 1: Personal Details

SECTION 2: Eligibility to Work in the UK

SECTION 3: Training & Qualifications

SECTION 4: Work Experience

SECTION 5: Fitness to Work

SECTION 6: DBS & Conduct

SECTION 7: Declarations & Consent