Clone of Manor Annual Health Questionnaire

Application Form
1. Application for the post of: (Tick all that apply)*

Residential Care WorkerDomiciliary Care WorkerSupport Worker
Other (please specify)
2. What hours and days are you available to work? (Tick all that apply)*

Full-timePart-timeEvenings (after 5pm)NightsDayCasual Worker (not set hours)
Other (please specify)
3. Approximate number of hours you are available to work each week?*
4. PERSONAL DETAILS
Name*
Address*

Street Address

Street Address Line 2

City/TownCounty

Post Code
Email Address*
example@example.com
Contact telephone Number*

Country CodeArea CodePhone Number
5. National Insurance Number*
6. Next of Kin Details
Next of kin name*
What is their relationship to you?*
Next of kin address*
Next of kin email address*
example@example.com
Next of kin phone number*

Country CodeArea CodePhone Number
7. Do you hold a full UK driving licence?*

YesNo
8. Do you drive your own vehicle?*

YesNo
9. Can you provide your right to work in the UK? (Passport, eVisa etc)*

YesNo
Date of expiry of eVisa held:

MonthDayYear
Date
11. What is your current or recent employment?
Post Held
Salary / hourly rate
Start date
Reasons for leaving (where applicable):
Employer's name and address
Date left/ notice period required
12. Have you provided us with a CV with your full employment history and previous education and training attended e.g. schools, college and university?*

YesNo
13. Tell us the schools, universities you attended and any studies if you have not already included this in your CV, including dates and qualification earned.
Schools attended
University/ College
Current Studies
14. If not provided on your CV please provide a list of our previous employment history (total history).
Post Held
Name and address of employer
From and to
Reason for leaving/change
15. If not provided on your CV please provide a list of our previous employment history (total history).
Post Held
Name and address of employer
From and to
Reason for leaving/change
16. Supporting information: Please indicate why you are applying for this particular post.*
17. Supporting information: Please describe how your skills and experience relate to the job description required for this post.*
18. Medical information:

If you are offered a position with the company you will be required to complete a health questionnaire and as a result may also undergo a medical examination.
Statement: I am prepared to undergo a medical examination if required and confirm that to the best of my knowledge there are no medical reasons which would prevent me from undertaking the duties of the post.*

YesNo
19. Rehabilitation of offenders act:

This post is NOT protected by the Rehabilitation of Offenders Act 1974. You are therefore required to disclose information of ALL convictions in a court of law, no matter when they occurred, or if they led to a conditional discharge. In the events of employment, failure to disclose all previous convictions may result in dismissal. All information will be treated in confidence and will only be taken into account when absolutely necessary.
Do you have any convictions (including motoring offences) to declare?*

YesNo
If YES please provide full details in the space below.
20. Disciplinary actions: Have you ever been subject to any disciplinary action(s)?*

YesNo
If you have been subject to any disciplinary actions, please state the date(s) and explain the level of the procedurei.e. warning or otherwise.
REFERENCES:

Please give the names and email addresses of three referees, one of whom should be the line manager of your present or most recent employer and one previous to that company as well. References are normally taken up after candidates have been shortlisted but before interview.
21. Address - Reference 1 - Full company details of your most recent employer
Name
Company
Email Address (this must be a company email address)
example@example.com
Phone Number

Country CodeArea CodePhone Number
22. Address - Reference 2 - Full company details of your 2nd most recent employer
Name
Company
Email Address (this must be a company email address)
example@example.com
Phone Number

Country CodeArea CodePhone Number
23. Address - Reference 3 - This can be a personal or professional reference
Name
Company
Email Address
example@example.com
Phone Number

Country CodeArea CodePhone Number
24. I consent for Manor Community to use and edit photographs or videos of me and information related to my experiences with the organisation on Facebook, Instagram, X, TikTok, or any other social media platform for the purpose of marketing and advertising.*

I consentI do not consent
25. Acknowledgements:

Please confirm how you would like Manor Community to use your details in respect of Facebook, Instagram, X, TikTok, or any other social media platform for the purpose of marketing and advertising (please choose one option).
I prefer that:*

My full name be usedMy first name only be usedI remain anonymousA nickname be used (please specify)
Tell us your preferred nickname
26. Confirm and Agree:*

I agree that I will not receive any monetary compensation.I confirm that I am of legal age to give my consent.
27. How would you describe yourself? e.g patient, confidence, good humour...*
28. What interests and hobbies do you have? e.g. fishing, racing, beauty, art, music...*
29. How did you hear about us?*
30. How did you hear about us?*

Social mediaWebsiteWord of mouthOtherReferral (please enter the name of the employee below)
Name of employee
31. I declare to the best of my knowledge that the information given above is correct. If appointed I understand that deliberate omissions, incorrect statement, canvassing of members of Manor Community/Oaktree Lodge in connection with this application, could jeopardise my employment and may lead to dismissal.

YesNo
Please verify that you are human*
Should be Empty:

Application Form

4. PERSONAL DETAILS

6. Next of Kin Details

11. What is your current or recent employment?