The Belfry Residential Care Home Job Application Form

The Belfry Job Application Form

Please fill out the following information to apply for the position.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Nationality
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
NI insurance number
Are there any restrictions on you taking up work in the UK?
If yes, please provide details.
Do you currently have a Driving Licence
Education
Qualifications gained
Other training
Upload Your Resume (PDF, DOC, or DOCX)

Cancelof
Cover Letter or Additional Comments (optional)
Leisure (Please note here your leisure interests, sports, hobbies or other pastimes)

When are you available to work?

Rows	Early(07:30-14:45)	Late(14:30-21:30)	Night(21:15-07:45)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Do you have any children?
If so, how old are they?

Employment history

Rows	Name and email address of Employer	Dates From/To	Job Title & Duties	Reason for leaving
1
2
3
4

References

Rows	Name and email address	Position	Organisation	Address	Tel no	May we contact prior to interview?
1
2
3
4

The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013 and 2020) provides that when applying for certain jobs and activities, certain convictions and cautions are considered ‘protected’. This means that they do not need to be disclosed to employers, and if they are disclosed, employers cannot take them into account. Guidance about whether a conviction or caution should be disclosed can be found on the Ministry of Justice website. Please detail any criminal convictions except those ‘spent’, or otherwise ‘protected’, under the Rehabilitation of Offenders Act 1974. If you have none, please state. In certain circumstances employment is dependent upon obtaining a satisfactory Disclosure & Barring Service Certificate from the Disclosure & Barring Service.
Have you ever been convicted in a Court of Law and/or cautioned in any offence?
If Yes, please give details.
Please detail here your reason for this application, your main achievements to date and the strengths you would bring to this position. specifically, please detail how your knowledge, skills and experiences meet the requirements of this role (as summarised in the Job Profile).
Because this position involves the care of vulnerale adults, employment is dependent on the following:

1. Your written consent to obtaining a disclosure certificate from the Criminal Records Bureau

2. Such disclosure being acceptable to us.

3. Proof of identity - birth or marriage certificate, a passport, and 2 letters addressed to yourself

4. Two satisfactory, written references

5. That you will supply a photograph of yourself for retention in our records

6. Evidence of physical or mental suitability for your work.
DECLARATION

1. I confirm that the above information is complete and correct and that ant untrue or misleading information will give my employer the right to terminate any employment contract offered

2. Should we require furhter information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my personnel file during employment and for up to six years thereafter and understand that information will be processed in accordance with the Data Protection Act

3. I agree that should i be successful in this application, I will, if required, apply to the Criminal Records Bureau for a basic disclosure. I understand that should I fail to do so, or should the disclosure not be to the satisfaction of the company, any offer of employment may be withdrawn or terminated.
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

DBS AGREEMENT
In consideration of the DBS check which I will be receiving from Care Check I agree to remain employed by Cloverform Ltd t/a The Belfry for a minimum period of six months after commencement of employment.

If my application is successful and I commence work with The Belfry I agree that if I leave my employment, for any reason, including dismissal, before the six month period which begins on my start date, I undertake to refund to my employer £66.80.

Less than 6 months after commencement of employment - 100%

In the event of my failure to pay I agree that my employer has the right as an express term of my Contract of Employment to deduct any outstanding amount due under this agreement from my salary or any other payments due to me on the termination of my employment in accordance with the legislation currently in force.
Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Health Questionnaire

Private and Confidential
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Position offered
If the answer is yes to any of the questions on this form, please give full details in the space provided of the dates, duration and outcome of the illness or condition. If we have any concerns about your fitness for work, employment will be subject to satisfactory medical reports.

Please add any addition information if Yes.
Tuberculosis, asthma, bronchitis or chest problems?
Chest pain, heart condition or raised blood pressure?
Blackouts, fits or attacks of giddiness?
Depression, mental illness or nervous breakdown?
Rheumatism or arthritis?
Back trouble?
Typhoid, paratyphoid or other infectious disease?
Digestive or bowel disease?
Diabetes, thyroid or other gland trouble?
Bladder or kidney trouble?
Dermatitis or skin trouble?
Varicose veins?
Vision or Hearing problems?
My other accident, operation or illness?
Have you any reason to believe you may be infected with any communicable disease?
My other current or recent medical condition or treatment which might affect your attendance or performance at work?
Do you intend to work night duties on a regular basis?
Any illness or medical condition that prevented you from attending work on your normal duties or activities for more than one week during the past year?
Any physical or mental impairment which has a substantial and long term effect on your ability to carry out day to day activities? If yes, please specify any special adjustments required in relation to work.
Do you smoke?
How many units of alcohol do you drink per week? (1 unit = 1/2 pint beer = 1 glass wine = 1 single whisky)
Signature

For Office Use Only

Rows	Date
Interview date
Acceptance letter
References sought
References received
Photograph received
CRB check sent/reveived
Started work
Ind. completed
Contract signed

Should be Empty:

The Belfry Job Application Form

DBS AGREEMENT

Health Questionnaire