Job Application Form
EMPLOYMENT APPLICATION FOR CHILD & ADULT CARE
Thank you for your interest in working with HG Care. Please fill all sections with as much detail as possible.
Date of Application
*
/
Day
/
Month
Year
Date
Tell us about yourself
What is your title?
*
Mr
Mrs
Miss
Other
First Name
*
Other Name(s)
Surname
*
Email
*
example@example.com
Mobile Number
*
Home Landline Number
*
Date of Birth
*
-
Day
-
Month
Year
Date
City of Birth
*
Country of Birth
*
Nationality
*
Have you ever changed either your first name or surname? (Marriage, Deed Poll, Adoption)
*
Yes
No
Previous Name
Date of Change
-
Day
-
Month
Year
Date
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Do you hold a UK/EU driver’s license?
*
Yes
No
Do you have access to a car or motorbike?
*
Yes
No
Do you have any access to transport? (e.g. electric bike)
*
Yes
No
Do you have the legal right to work in the UK?
*
Yes
No
Full time or Part Time?
*
Full time
Part Time
Preferred Shift Hours
*
7am till 2pm
3pm till 9pm
Weekend Only
All Day (7am till 9pm)
Preferred areas of work
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Address Details
Must Provide Previous 5 Year Address History
Current Home Address
*
House Number and Street Name
Street Address Line 2
City
Postal / Zip Code
Date Moved into Address
*
-
Day
-
Month
Year
Date
Previous Address 1
*
House Number and Street Name
Street Address Line 2
City
Postal / Zip Code
Date moved in Address 1?
*
-
Day
-
Month
Year
Date
Previous Address 2
*
House Number and Street Name
Street Address Line 2
City
Postal / Zip Code
Date moved in Address 2?
*
-
Day
-
Month
Year
Date
Previous Address 3
*
House Number and Street Name
Street Address Line 2
City
Postal / Zip Code
Date moved in Address 3?
*
-
Day
-
Month
Year
Date
Previous Address 4
*
House Number and Street Name
Street Address Line 2
City
Postal / Zip Code
Date moved in Address 4?
*
-
Day
-
Month
Year
Date
Previous Address 5
*
House Number and Street Name
Street Address Line 2
City
Postal / Zip Code
Date moved in Address 5?
*
-
Day
-
Month
Year
Date
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Care Experience
Please provide previous care experience
*
Why do you want to become a Carer?
*
Next of Kin Details
Name
*
First Name
Last Name
NOK Relationship
*
NOK Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NOK Mobile number
*
NOK Email Address
example@example.com
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Education & Training
Please provide your previous education and training information below
Name of School
*
Years Attended From
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Day
-
Month
Year
Date
Years Attended To
-
Day
-
Month
Year
Date
List of Subjects and Grade
*
Please list any languages spoken and whether these are fluent or conversational
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Previous Jobs
Starting with the most recent, please provide some details about your previous employment history, covering the last 10 years.
Most Recent Job
Employer Name
*
Role
*
Employed from
*
-
Day
-
Month
Year
Date
Employed to
*
-
Day
-
Month
Year
Date
Duties & Responsibilities
*
Reasons for leaving
*
Have You had a previous Job?
*
Yes
No
2nd Previous Employer
Must provide previous 10 Year Working History
Employer Name
*
Role
*
Employed from
*
-
Day
-
Month
Year
Date
Employed to
*
-
Day
-
Month
Year
Date
Duties & Responsibilities
*
Reasons for leaving
*
Have You had a previous Job?
*
Yes
No
3rd Previous Employer
Must provide previous 10 Year Working History
Employer Name
*
Role
*
Employed from
*
/
Day
/
Month
Year
Date
Employed to
*
/
Day
/
Month
Year
Date
Duties & Responsibilities
*
Reasons for leaving
*
If still less than 10 years, please provide all other Jobs
*
Include Company Name, Role and Dates
Employment Gaps
*
If there are any gaps in your employment history, please state why and when below (for example, pregnancy, travelling etc..)
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Reference Information
Please provide details of two individuals who can provide us with a character reference. One reference must be your most recent employer. Reference two can be from a previous Employer, School/University or Friend/Neighbour
Reference 1
Name
*
First Name
Last Name
Position
Organisation
Email
example@example.com
Telephone
Relationship to yourself
*
Reference 2
Name
*
First Name
Last Name
Position
Organisation
Email
example@example.com
Telephone
Relationship to yourself
*
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Equal Opportunities
We are committed to equal opportunities in our recruitment process and in order to find out more about how we are doing with this we need to collect monitoring data. This monitoring form is voluntary but the information we collect here is useful as it helps us to ensure that we are an inclusive employer with a diverse workforce. All information you supply on this form will be kept confidential and has no part in the selection process.
How did you hear of the post?
*
Social Media
Word of mouth
Visited office branch
Online job website
Other
What is your ethnic origin?
Asian / Asian British
Bangladeshi
Chinese
Indian
Pakistani
British
African
Caribbean
Prefer Not to Say
What is your gender?
Female
Male
Prefer not to say
What is your marital status?
Single
Married
Separated, but still legally married Divorced
Widowed
Prefer not to say
What is your religious belief?
Atheist
Buddhist
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
Muslim
Sikh
Hindu
Jewish
Prefer not to say
Do you consider yourself to be disabled?
Yes (please state below)
No
Prefer not to say
Please state
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Health Declaration
How many days were you absent from work due to sickness in the last year?
Have you ever experienced any of the following?
Allergies
Eczema
Dermatitis
Other skin troubles
None
Do you suffer or have you ever suffered from any of the following?
Epilepsy
Migraine
Asthma
Angina
Heart trouble
Any other-long term or a strict medication timetable
None
Have you ever suffered from any mental illness?
Anxiety
Depression
None
Prefer not to say
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Declarations of Conviction
Have you ever been convicted of any offence?
*
Yes
No
If you have answered YES, you MUST provide details of all offences committed included those regarded as ‘spent’.
Declaration
*
I declare that all information provided across all sections of this application is correct and that any convictions have been stated. I understand that any information found to be incorrect will be treated as gross misconduct and I will be liable for dismissal without notice. I also give my consent for the people stated in the reference section to be contacted for reference purposes.
Signature
*
Submit
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