Employment Application Form

1
Your Title* This field is required.
Miss
Mrs
Mr
Ms
2
Name:* This field is required.
First Name
Last Name
3
Email* This field is required.You'll get a copy of your Application Form emailed to this address once you've submitted it.
example@example.com
4
What vacancy are you applying for?
Visiting Care Professional
Live-in Care Professional
Office Role
5
Which branch are you applying to?* This field is required.
Aylesbury
Barnet and Enfield
Bedford
Brentwood
Dorchester and Weymouth
East Dorset
East Hertfordshire
Edgware and Finchley
Elmbridge
Epsom and Reigate
Fareham and Gosport
Farnham
Glasgow South
Horsham and Crawley
Isle of Wight
Luton and Dunstable
Maidenhead and Windsor
Marlow and Chilterns
Mid Cheshire
Mid-Sussex
Milton Keynes
New Forest
Northwood and Ruislip
Poole and Bournemouth
Reading
Oxford and Bicester
St Albans
Southampton
South Kent
South Leicestershire
South Warwickshire
South Oxfordshire
Sussex South
Watford
Wimbledon and Kingston
Wokingham and Bracknell
Woodford Green
6
Date of Birth* This field is required.DD/MM/YYYY
7
Home Address:* This field is required.
Street Address
Street Address Line 2
City
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
National Insurance Number
9
Mobile Phone Number:* This field is required.
Area Code
Phone Number
10
Emergency Contact Details* This field is required.
Name
Relationship
Telephone Number
11
Do you have a right to work in the UK?* This field is required.
YesNo
12
Nationality* This field is required.
13
How were you referred to us?* This field is required.
Walk-In
Employee
Indeed
Facebook
Other (please specify)
GoodOaks Website
14
Other:
15
If you have a CV, please upload it here:If not, just press Next
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
16
How many hours per week would you like to work?If you are applying for a Live-in Care Professional role, press Next
17
Your AvailabilityIf you are applying for a Live-in Care Professional role, press Next
Yes
No
Are you willing to work some split shifts?
Row 0, Column 0
Row 0, Column 1
Are you willing to work some sleeping nights?
Row 1, Column 0
Row 1, Column 1
Are you willing to work some waking nights?
Row 2, Column 0
Row 2, Column 1
Are you looking for a part-time job?
Row 3, Column 0
Row 3, Column 1
Are you looking for a full-time job?
Row 4, Column 0
Row 4, Column 1
Are you willing to work some split shifts?
Are you willing to work some sleeping nights?
Are you willing to work some waking nights?
Are you looking for a part-time job?
Are you looking for a full-time job?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
1 of 5
18
Your AvailabilityIf joining us in a Care role, please describe your weekly availability, including any commitments you need to work around. If not, please skip this section.
Huge
Large
Normal
Small
Ok
Ok
19
Availability - Live-in Care
Please Select
Please Select
1 week on - 1 week off
2 weeks on - 1 week off
2 weeks on - 2 weeks off
3 weeks on - 3 weeks off
4 weeks on - 4 weeks off
4+ weeks on
Your preferred work pattern
20
Current / Most Recent Employer
Organisation Name and Address
Employed From (MM/YY) To (MM/YY) Please include full dates
Manager Name
Email Address and Telephone Number
Salary and Job Title
Reasons for leaving/wishing to leave
Duties
Please Select
Please Select
Yes
No
May we contact this employer for a reference?
21
Next EmployerThis is your second most recent employer
Organisation Name and Address
Employed From (MM/YY) to (MM/YY)
Manager Name
Email Address and Telephone Number
Salary and Job Title
Reasons for leaving/wishing to leave
Duties
Please Select
Please Select
Yes
No
May we contact this employer for a reference?
22
Next EmployerIf you don't have any more employers to enter, just press Next
Organisation Name and Address
Employed From (MM/YY) to (MM/YY)
Manager Name
Email Address and Telephone Number
Salary and Job Title
Reasons for leaving/wishing to leave
Duties
Please Select
Please Select
Yes
No
May we contact this employer for a reference?
23
Next EmployerIf you don't have any more employers to enter, just press Next
Organisation Name and Address
Employed From (MM/YY) to (MM/YY)
Manager Name
Email Address and Telephone Number
Salary and Job Title
Reasons for leaving/wishing to leave
Duties
Please Select
Please Select
Yes
No
May we contact this employer for a reference?
24
Next EmployerIf you don't have any more employers to enter, just press Next
Organisation Name and Address
Employed From (MM/YY) to (MM/YY)
Manager Name
Email Address and Telephone Number
Salary and Job Title
Reasons for leaving/wishing to leave
Duties
Please Select
Please Select
Yes
No
May we contact this employer for a reference?
25
Next EmployerIf you don't have any more employers to enter, just press Next
Organisation Name and Address
Employed From (MM/YY) to (MM/YY)
Manager Name
Email Address and Telephone Number
Salary and Job Title
Reasons for leaving/wishing to leave
Duties
Please Select
Please Select
Yes
No
May we contact this employer for a reference?
26
Next EmployerIf you don't have any more employers to enter, just press Next
Organisation Name and Address
Employed From (MM/YY) to (MM/YY)
Manager Name
Email Address and Telephone Number
Salary and Job Title
Reasons for leaving/wishing to leave
Duties
Please Select
Please Select
Yes
No
May we contact this employer for a reference?
27
We need to record your full employment history from when you left education to present day. If you have had more employers than listed above, please outline these here along with ANY gaps in your employment (dates and reasons):You can press PREVIOUS to return to the Employer section.
28
Can we contact your two most recent employers for a reference?If so, have you provided correct email and telephone details for them?
YESNO
29
Reference 1We use a system called zinc for references and DBS, ensure the provided details are also used when completing your zinc check. Please also include a contact number so we can verify your reference.
Name
Years known
Relationship/Position
Email Address
Address (If no Email Address)
Contact Number
30
Reference 2We use a system called zinc for references and DBS, ensure the provided details are also used when completing your zinc check. Please also include a contact number so we can verify your reference.
Name
Years known
Relationship/Position
Email Address
Address (If no Email Address)
Contact Number
31
Please provide details of any other individuals or organisation who can be contacted to provide a reference and state how they are known to you:
Huge
Large
Normal
Small
Ok
Ok
32
Your Educational History
Name and Address of School/College/University
When did you leave education?
Final qualifications achieved
33
Educational Establishment 2
Name and Address of School/College/University
Dates of attendance (from - to)
Qualifications achieved
34
Relevant care training and certifications:Please bring originals of these certificates with you when you come to the office
35
Reference 1 Name:* This field is required.
First Name
Last Name
36
Relationship* This field is required.
37
Email Address* This field is required.
38
Phone Number* This field is required.
Area Code
Phone Number
39
Years Known:* This field is required.
40
Address* This field is required.
Street Address
Street Address Line 2
Town
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
41
Reference 2
42
Reference 2 Name:* This field is required.
First Name
Last Name
43
Relationship* This field is required.
44
Email Address* This field is required.
45
Phone Number* This field is required.
Area Code
Phone Number
46
Years Known:* This field is required.
47
Address* This field is required.
Street Address
Street Address Line 2
Town
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
48
Signature
49
Have you ever registered as disabled?
YesNo
50
Have you ever registered as disabled?
Yes
No
51
If yes, please give details
52
Have you ever claimed industrial injury/disease compensation or benefits or have you ever left or had to modify a job due to illness or injury?
YesNo
53
Have you ever claimed industrial injury/disease compensation or benefits?
Yes
No
54
If yes, please give details
55
Have you ever left or had to modify a job due to illness or injury?
Yes
No
56
Fits, blackouts, epilepsy, fainting attacks, severe head injuries, frequent or severe migraine headaches* This field is required.
YesNo
57
Fits, blackouts, epilepsy, fainting attacks, severe head injuries, frequent or severe migraine headaches
Yes
No
58
If yes, please give details
59
Chest problems, including asthma, bronchitis, emphysema, pleurisy, persistent cough or breathlessness* This field is required.
YesNo
60
Chest problems, including asthama, bronchitis, emphysema, pleurisy, persistent cough or breathlessness
Yes
No
61
If yes, please give details
62
Heart or circulation problems, e.g. raised blood pressure, angina, stroke, chest pains* This field is required.
YesNo
63
Heart or circulation problems, e.g. raised blood pressure, angina, stroke, chest pains.
Yes
No
64
If yes, please give details
65
Eye disease, severe vision defects or defective colour vision* This field is required.
YesNo
66
Eye disease, severe vision defects or defective colour vision* This field is required.
Yes
No
67
If yes, please give details
68
Ear conditions, such as hearing loss* This field is required.
YesNo
69
Ear conditions, e.g. recurring discharge or hearing loss* This field is required.
Yes
No
70
If yes, please give details
71
Mental health conditions, such as depression, anxiety, phobias, schizophrenia, eating disorders or self-harm including overdoses* This field is required.
YesNo
72
Mental health conditions, such as schizophrenia, depression, anxiety, phobias, eating disorders or self-harm including overdoses* This field is required.
Yes
No
73
If yes, please give details
74
Addiction to alcohol or any other sustances* This field is required.
YesNo
75
Addiction to alcohol or any other substances* This field is required.
Yes
No
76
If yes, please give details
77
Neck, back or other joint problems including arthritis, slipped disk, sciatica, recurrent backache* This field is required.
YesNo
78
Neck, back or other joint problems including arthritis, slipped disk, sciatica, recurrent backache.* This field is required.
Yes
No
79
If yes, please give details
80
Skin conditions, e.g. eczema, psoriasis, dermatitis* This field is required.
YesNo
81
Skin conditions e.g. eczema, psoriasis, dermatitis* This field is required.
Yes
No
82
If yes, please give details
83
Gastro-intestinal conditions, including ulcers, irritable bowel syndrome, typhoid or persistent diarrhoea
YesNo
84
Gastro-intestinal conditions, including ulcers, irritable bowel syndrome, typhoid or persistent diarrhoea* This field is required.
Yes
No
85
If yes, please give details
86
Diabetes, thyroid or any other glandular condition* This field is required.
YesNo
87
Diabetes, thyroid or any other glandular condition* This field is required.
Yes
No
88
If yes, please give details
89
Liver, kidney or bladder disease* This field is required.
YesNo
90
Liver, kidney or bladder disease* This field is required.
Yes
No
91
If yes, please give details
92
Hernia or rupture* This field is required.
YesNo
93
Hernia or rupture* This field is required.
Yes
No
94
If yes, please give details
95
Major operations* This field is required.
YesNo
96
Major operations* This field is required.
Yes
No
97
If yes, please give details
98
Allergies to any substances* This field is required.
YesNo
99
Allergies to any substances* This field is required.
Yes
No
100
If yes, please give details
101
Do you have any other medical condition or disability which you feel may require adjustment to your work or working environment* This field is required.
YesNo
102
Any other medical condition or disability which you feel may require adjustment to your work or working environment* This field is required.
Yes
No
103
If yes, please give details
104
Are you taking any regular medications?* This field is required.
YesNo
105
Are you taking any regular medications?* This field is required.
Yes
No
106
If yes, please give details
107
Do you smoke or drink?* This field is required.
YesNo
108
Do you smoke or drink?* This field is required.
Yes
No
109
If yes, please give details
110
Infectious DiseasesDo you have, or have you ever had any of the following?
Please Select
Please Select
Yes
No
Chicken Pox
If yes, please give details
Please Select
Please Select
Yes
No
Tuberculosis (TB)
If yes, please give details
Please Select
Please Select
Yes
No
Hepatitis B or C
If yes, please give details
Please Select
Please Select
Yes
No
Human Immunodeficiency Virus (HIV)
If yes, please give details
111
Please list all up to date vaccinations* This field is required. (i.e. Covid 19, Tetanus, MMR)
112
Have you had the Covid-19 Vaccine?
YESNO
113
What do you like to do in your spare time?
114
Do you have a DBS registered with the Update Service?* This field is required.
YesNo
115
If Yes, please provide DBS Certificate Number:
116
Do you have a criminal conviction, caution, reprimand or warning? This does not apply to convictions which are spent under the Rehabilitation of Offenders Act 1974?* This field is required.
YesNo
117
If yes, please describe the convictions fully, listing the dates and nature of the offences.
118
Do you consent to an enhanced criminal record check from the Disclosure and Barring Service?* This field is required.
YESNO
119
Do you have a criminal conviction, caution, reprimand or warning? This does not apply to convictions which are spent under the Rehabilitation of Offenders Act 1974.
YES
NO
120
Have you ever been named or subjected to an investigation or inquiry under Safeguarding procedures or received a warning via Disciplinary action for any reason?* This field is required.
121
Are you included in the DBS Adults' or Children's Barred Lists?* This field is required.
122
In the last 10 years, have you lived outside of the UK for a period of 12 months or more? If yes, please provide details
123
What attracted you to a care role, and GoodOaks in particular?
124
Applicant Declaration"To the best of my knowledge the information on this application is complete and correct. I understand that falsifying information may disqualify me from being considered for employment by GoodOaks and may be cause for dismissal."
125
How would you rate this paperless application form compared to standard paper versions?* This field is required.
1
2
3
4
5
Terrible
Brilliant
Should be Empty: