Domiciliary Care Assistant Application

Domiciliary Care Assistant Application

Apply for a role by completing your personal, professional, and availability details.
Applicant Information

Please provide your current contact details.
Full Name*

First NameLast Name
Maiden or Previous Names (if applicable)
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
YesNo
YesNo
YesNo
Position Applying For & Availability

Tell us about the role you are interested in and your availability.
Role Applying For*
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
MorningsAfternoonsEveningsNights
Other Availability Comments
Full timePart timeBank
Other Comments on Contracted Hours
Preferred Start Date*

MonthDayYear
Date
Company websiteJob board (e.g. Indeed)Social mediaWord of mouthReferralOther
Qualifications & Training (relevant to care)

List your care-related qualifications and training.
Qualifications & Training
Employment History (last 5 years or since leaving full-time education)

Please provide your full employment history.
Employment History
Please explain any gaps in employment
References (must not be family members)

Please provide contact details for two references.
Reference 1 Name*
Reference 1 Relationship*
Reference 1 Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 Email Address*
example@example.com
YesNo
Reference 2 Name*
Reference 2 Relationship*
Reference 2 Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Email Address*
example@example.com
YesNo
Additional Information (optional)

This section is not mandatory.
Do you speak any other languages besides English?
Are you related to any staff members or service users?
YesNo
YesNo
YesNo
Care Experience

Share your experience in care roles.
YesNo
Personal careMedicationDementiaMobility supportMeal preparationCompanionshipEnd of life careClients with swallow problemsUsing hoistsElectronic record keepingElectronic rotas/requestingCommunicating with familiesWorking independentlyWorking as part of a team
Safeguarding & Criminal Record Declaration

This section is confidential and will only be seen by those directly involved in the recruitment process.
YesNo
YesNo
If yes to either of the above, please provide details
Health & Wellbeing

Let us know if we can support you during the interview or in the workplace.
YesNo
If yes, please provide brief details
YesNo
If yes, please provide brief details
Emergency Contact

Please provide details for someone we can contact in an emergency.
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Supporting Information & Declaration

Please read the privacy statement and declaration below.
If you wish you can upload your CV here:

Cancelof
Privacy Statement: We collect and store your information only for recruitment purposes. By submitting this form, you agree to us holding the details you’ve provided. If you are shortlisted, we may also record shortlisting scores and interview notes. We will keep your data until the vacancy is filled. Once the recruitment process is complete, we will either delete your data or ask if you’d like us to keep it for future opportunities. Your data will be securely stored by the Registered Manager and only used for this role. You have the right to: • Access your data • Correct or update your data • Withdraw your consent • Restrict how your data is used • Be informed about how your data is processed • Request deletion of your data ('right to be forgotten')
Signature*

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Date*

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Date
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Domiciliary Care Assistant Application

Applicant Information

Position Applying For & Availability

Qualifications & Training (relevant to care)

Employment History (last 5 years or since leaving full-time education)

References (must not be family members)

Additional Information (optional)

Care Experience

Safeguarding & Criminal Record Declaration

Health & Wellbeing

Emergency Contact

Supporting Information & Declaration