Homecare Assistant Application Form

Homecare Assistant Application Form

Apply for a Homecare Assistant position. Please complete all sections to support CQC compliance.
Personal Information

Please provide your personal details.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: 00000000000.
Emergency Contact Name

First NameLast Name
Relationship of Emergency Contact
Phone Number of Emergency Contact
Please enter a valid phone number.Format: 00000000000.
Please provide a valid Passport.

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Proof of Address - Number 1

Accepted Papers - Utility Bill, Driving Licence, Bank or Credit Card Statement, Council Tax Bill. Must be dated within the past 3 months.
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Proof of Address - Number 2 (Must be different to Number 1)

Accepted Papers - Utility Bill, Driving Licence, Bank or Credit Card Statement, Council Tax Bill. Must be dated within the past 3 months.
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Do you have the Right To Work in the UK?

Other
Share Code
I confirm that I am currently employed by the sponsoring employer named on my Skilled Worker visa and that my sponsorship remains valid. I understand that any additional work I undertake must comply with my visa conditions and that providing false information may affect my eligibility to work.
Sponsor Name
We will only contact them if requesting a reference with your permission
Job Title with Sponsor
We will only contact them if requesting a reference with your permission
If you currently have student visa, upload a copy of your term dates.

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Proof of your National Insurance Number.

This can be a payslip, P45, P60 or letter from HMRC.
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Do you have a valid Driving licence?
Attach a copy of your driving licence, if your licence is international, please also provide your UK Licence.

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Do you have any unspent criminal convictions?
Consent to carry out enhanced DBS and background checks
Do you have a DBS that is registered on the Update Service?
Please upload front copy of your DBS

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Please upload Back copy of your DBS

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Upload your CV. This MUST have your work history since the age of 16.

This is from the day of your 16th birthday and must include any gaps. This includes any gaps of more than 7 days. You can find a list below to include these if they are not present.
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Please explain any employment gaps, if you have any. This must go back to the date your turned 16 years old. Anything over 2 weeks is classed as an employment gap, if you require a larger form for this, please ask for one. This is a CQC Safer Recruitment policy and must be completed. Example: 01/03/2022 - 14/03/2023 Looking for work 01/07/2022 - 01/01/2023 Raising my family

Rows	Date from	Date to	Reason for Gap
Employment Gap 1
Employment Gap 2
Employment Gap 3
Employment Gap 4
Employment Gap 5
Employment Gap 6
Employment Gap 7

Please upload any healthcare related certificates or qualifications from further training or education. This could include your Care Certificate, Oliver McGowan, Moving and Handling of People or any Complex Care training you have had.

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Have you recently travelled outside the UK in the last 6 months? If yes, please give details (country, dates, and reason for travel) so we can assess any relevant occupational health considerations. If you require more space the the 2 provided columns, please contact the office.

Rows	Add Information Below
County
Date left the UK
Date Returned
Reason for travel
Any needed vaccinations taken (give details)

Do you have any allergies that we should be a wear of?
Do you have any disabilities that we may need to support you with?
We are a disability-inclusive employer and are committed to creating a supportive and inclusive working environment. If you have a disability or health condition, we encourage you to let us know so we can consider reasonable adjustments in line with the Equality Act 2010.
Do you declare that to the best of your knowledge you are physically and mentally fit to perform the duties outlined in your job description?
Please note that domiciliary care involves lone working, travelling between service users’ homes, moving and handling, administering medication, and responding to individuals with complex physical, emotional and behavioural needs. All employees must be able to meet the required physical, mental and emotional health standards necessary to carry out these duties safely and effectively, with or without reasonable adjustments.
References

Please provide two professional references, from your last employer and one from an employer of your choice (both companies must have known you professionally for at least 6 months). One character reference, (a reference you've known on a personal level for at least 6 months).

Professional Reference 1 (Most recent employer, preferably care based, if you have a sponsor, this must be them). This must also be a UK based employer and be a work based domain email address. Any Gmail/Hotmail/Yahoo etc. email addresses will not be accepted.

Rows	Professional Reference 1
Contact Name
Business Name
Professional Email Address
Phone Number
Address
Post Code
Capacity and timeframe in which known

Professional Reference 2 - This maybe an overseas reference but again must be a work based domain email address. Any Gmail/Hotmail/Yahoo etc. email addresses will not be accepted.

Rows	Professional Reference 2
Contact Name
Business Name
Professional Email Address
Phone Number
Address
Post Code
Capacity and timeframe in which known

Character Reference - This person must have known you for at least 2 years and be of good character themselves.

Rows	Character Reference
Contact Name
Email Address
Phone Number
Address
Post Code
Capacity and timeframe in which known

Sign

Please sign below to confirm all the details that you have provided are correct to the best of your knowledge
Declaration: I give permission for you to contact the references that I have provided.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Homecare Assistant Application Form

Personal Information

References

Sign