Job Application Form
Please Fill Out the Form Below to Submit Your Job Application!
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Position Applied for
*
Please Select
Dom Care Care Worker
Carers Break Care Worker
Supported Living Support Worker including Mental Health
Dom Care - Senior Care Worker
Carers Break - Senior Care Worker
Preferred Employment Type
*
Please Select
Full Time
Part Time
Relief/Bank Worker
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
UK National Insurance Number (if you have one)
Right to Work: Do you require permission to work in the UK
*
Yes
No
If answer Yes, please supply details of any visa currently held, number, start/expiry dates and details of any restrictions:
Do you consider yourself to have a disability?
*
Please Select
YES
NO
Please state the type of impairment which applies to you. People may experience more than one impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.
Please Select
Physical Impairment
Sensory Impairment
Mental Health
Other
If you have a disability, do you require any reasonable adjustments to be made during the recruitment process, Including interview?
*
Yes
No
If Yes, please give details
If you have a disability, do you wish to be considered under the Disability Confident Interview Scheme if you minimum criteria as specified in the Person Specification?
*
Yes
No
Do you have a valid driving license for the UK?
*
Please Select
YES
NO
Please specify the vehicle category for which you hold a license? (all that apply)
Motorbike (A)
Car (B)
Car with trailer (B + E)
Medium Sized Vehicle (C1)
Medium Sized Vehicle (C1 + E)
Passenger Carrying Vehicle (D)
Passenger Carrying Vehicle (D+E)
C1 Provisional License
No License
Do you have access to a vehicle which can be used for work purposes?
Please Select
YES
NO
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Education and Professional Qualifications
Include in this section all the relevant qualifications. Please also indicate subjects currently being studied.
Please include Subject, Qualification, Place of Study, Grade and Year
*
Training Courses Attended
Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking, together with the date completed or to be completed.
Please include Course Title, Training Provider, Duration, Completion Date
*
Supporting Statement
You must provide supporting information, including your reasons for applying for this position and details that demonstrate how you meet the person specification. This should include relevant skills, knowledge, experience, voluntary activities, training, or qualifications. All responses must be clearly linked to the job description and person specification.
Experience
*
Skills
*
Knowledge
*
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Employment History
Please record below the details of your full employment history starting with your most recent Employer.
Employer
Position Held
Start Date
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Day
-
Month
Year
Date
End Date
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Day
-
Month
Year
Date
Reasons for Leaving
Employer
Position Held
Start Date
-
Day
-
Month
Year
Date
End Date
-
Day
-
Month
Year
Date
Reasons for Leaving
Employer
Position Held
Start Date
-
Day
-
Month
Year
Date
End Date
-
Day
-
Month
Year
Date
Reasons for Leaving
Employer
Position Held
Start Date
-
Day
-
Month
Year
Date
End Date
-
Day
-
Month
Year
Date
Reasons for Leaving
Any other employment including Employer, Position Held, Dates Worked and Reason for Leaving
Gaps in employment, training or education. Please detail each period of more than 4 weeks when you were not in employment or education/training.
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References
Please give the names of the people who have agreed to supply references. If you are or have been employed these should be your two most recentemployers, your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. If you are a student please provide contact details of a teacher at your school, college oruniversity. Please note that personal references such as friends and relatives are not acceptable. For all posts written references obtained must cover the preceding 3 years of employment. For all positions you must provide2 references. We suggest providing 3 references if possible as an alternative option.
Referee 1
I consent to Nurtrio contacting the referees named below
*
Title
*
Please Select
MS
MRS
MR
DR
OTHER
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship
*
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Referee 2
Title
*
Please Select
MS
MRS
MR
DR
OTHER
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship
*
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Referee 3 (Alternative)
Title
Please Select
Ms
Mrs
Mr
Dr
Other
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship
Email
example@example.com
Phone Number
-
Area Code
Phone Number
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Declarations
Are you a relative or a partner of, or do you have a close personal relationship with any employee of Nurtrio?
*
Yes
No
If yes, please state their full name and post title
Have you previously been employed or sought employment with Nurtrio?
*
Yes
No
If yes, please provide details
We ask all applicants to share information about past allegations, disciplinaries andinvestigations at the application stage and seek to verify the information through employment references and other pre-employment checks (where appropriate). At interview, or in a separate confidential discussion, we will ensure that an open and measured discussion takes place on the subject of any allegations, investigations and disciplinary matters which might be relevant tothe post.
Conduct Declaration
Have you ever been subject to any sanctions being placed on your professional registration, by a regulatory or licensing body in any country? Sanctions may include: Warnings, conditions, limitations, suspension, removal or any other restrictions that have applied to your professional registration.
*
Yes
No
N/A
If yes, please provide details of any sanctions and the name + addressof the regulatory or licensing body concerned
Have you ever been dismissed for misconduct from any employment,volunteering, office, or other position previously held by you?
*
Yes
No
If yes, please provide details
Have you ever been under investigation for or subject to anydisciplinary sanctions in relation to your conduct at the time of yourdismissal/leaving any employment, volunteering, office, or other positionpreviously held by you?
*
Yes
No
If yes, please provide details
We will only ask those candidates who have been selected forinterview to complete a criminal record self declaration form or provide awritten disclosure statement to give them the opportunity to provide sufficient information. At interview, or in a separate confidential discussion, we will ensure that an open and measured discussion takes place on the subject of any offences that might be relevant to the position. We will only carry out criminal record checks with DBS on successful candidates at the appropriate level for the role applied for. Failure to provide accurate and truthful information is considered a serious matter. If it becomes apparent that inaccurate or incomplete information has been provided, we will need to establish why. Any finding of serious misdirection or intent todeceive will result in an application being disqualified or, if appointed, disciplinary action being taken and/or dismissal.
For posts involving working in Regulated Activity only:
Applicants need to be aware that it is a criminal offence to apply for a post that is subject to an enhanced DBS with barred list check (i.e. adults, children or both) if they have been barred from engaging in regulated activity with the relevant group (i.e. adults, children or both). If you are not barred from engaging in regulated activity with (i.e. adults, children or both), but have been referred to the DBS for consideration to be added to one of the barred lists, you must also declare this information.
DBS Barred Lists
This post involves working in Regulated Activity under the SafeguardingVulnerable Groups Act 2006 and is subject to an enhanced DBS with barred listcheck (i.e. adults, children or both). It is a criminal offence to apply for oraccept a position working with adults at risk and/children if you have beenbarred from engaging in regulated activity with the relevant group (i.e.adults, children or both).
Are you included in the list of people barred from working with adultsmaintained by the Disclosure and Barring Service (DBS) under the SafeguardingVulnerable Groups Act 2006?
*
Please Select
Yes
No
N/A
Are you included in the list of people barred from working with childrenmaintained by the Disclosure and Barring Service (DBS) under the SafeguardingVulnerable Groups Act 2006?
*
Please Select
Yes
No
N/A
If you are not currently barred from working with adults at riskand/children under the Safeguarding Vulnerable Groups Act 2006, have you beenreferred to the Disclosure and Barring Service (DBS) for consideration to beadded to one of the barred lists?
*
Please Select
Yes
No
If Yes, please provide details
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Additional Information Sheet (if required)
Application Declaration
The information in this form is true and complete. I agree that any deliberate omission, falsification or mis representation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This applies equally to any medical questionnaire/forms I may complete.
I agree to the above declaration.
*
Date
*
-
Day
-
Month
Year
Date
Nurtrio is a data controller in respect of personal information thatwe process in connection with our application. In line with current GeneralData Protection Regulations, we respect individual’s rights to privacy and tothe protection of personal information. We will not share your personalinformation without your consent. For more information about how we use your dataplease see our Privacy Notice.
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