Jobs

Post details

Post applied for:

Salary Expectation:

If appointed when can you start:

Personal details

Title:

First name:

Middle Name:

Family Name / Surname:

Maiden or previous name(s):

Home address & Post Code:

Previous addresses (last 5 years including dates):

Have you ever lived or worked abroad? (if so provide details including dates)

Email address:

Daytime telephone number:

Home telephone number:

Mobile telephone number:

National Insurance number:

Teacher’s Reference number:

Do you have a current full Driving Licence?

Do you have use of a car?

Do you have Business Car Insurance? (this will be needed to commute between sites)

Current or most recent employer

Organisation Name & Address

Job title:

Date appointed:

Salary

Are you still employed by this organisation?

☐Yes ☐ No

Date and reason for leaving (if applicable)

Employer History

Employer Name & Address

Job Title

Dates of Employment From / To

Reason for leaving

Salary

Other History

(Please ensure that you provide a complete chronological history by listing below any periods not covered above in your employment history, e.g. travel, unemployment, sabbatical, carer responsibilities etc.)

From

To

Reason

Letter of Support – why are you applying for this position?

• Please write in support of this application, showing how your experience, training, qualifications and interests are relevant and how you would contribute to the requirements of the advertisement, job profile and person specification.

• You may complete this information below or attach as a separate word-processed sheet.

Working Time Regulations 1998

The working time regulations were introduced on 1 October 1998 and working hours in the UK are now governed by statute. Employment which you intend to continue if successfully appointed to the position applied for must be declared below.

Section 1 – No other employment

I confirm that I do not have any other employment

Signature:

If form has been completed electronically, please place an ‘x’ in this box to indicate your consent à

☐

Print Name:

Date:

Section 2 – Other employment

Job Title

Weekly Hours:

Start Time

End Time

Signature:

If form has been completed electronically, please place an ‘x’ in this box to indicate your consent à

☐

Print Name:

Date:

DBS

Do you hold a current DBS Y/N

If Yes, please insert DBS cert no:

Referees

One must be your present or most recent employer. The other must be a previous employer unless you have had no previous employment, in which case, a character reference will be needed or a reference from a School, Higher Educational Establishment or other professional. E.g. Tutor/Teacher

References will not be accepted from relatives or from people writing solely in the capacity of friends.

1) Present/Most recent employer

Name:

Organisation Name:

Address:

Postcode:

Job Title:

Relationship to applicant:

Telephone no.

Email address:

May we contact this referee prior to interview:

☐ Yes ☐ No

2) Previous Employer

Name:

Organisation Name:

Address:

Postcode:

Job Title:

Relationship to applicant:

Telephone no.

Email address:

May we contact this referee prior to interview:

☐ Yes ☐ No

NOTE: References will be taken up if you are called for interview. In view of the nature of the job no offer of employment can be made without these. We also reserve the right to take up employment references from previous employers listed in "Previous Employment". If, for any reason, you feel unable to give your present or most recent employer as a referee, please send a covering letter explaining why.

Declaration by Applicant

Do you consider yourself to have a disability as defined in The Equality Act 2010?

☐ Yes ☐ No

If yes, please detail any reasonable adjustments that you would require if you were selected to attend an interview/assessment event

If yes, please provide further information:

Have you ever been known to any children’s services department or to the police as being a risk or potential risk to children?

☐Yes ☐ No

If yes, please provide further information:

Have you been the subject of any disciplinary investigation and/or sanction by any organisation due to concerns about your behaviour towards children or have any of these pending?

☐ Yes ☐ No

If yes, please provide further information:

Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amended) 2013? http://www.justice.gov.uk/downloads/offenders/rehabilitation/rehabilitation-offenders.pdf

☐ Yes ☐ No

If yes, please provide further information:

Have you ever been barred from working with children?

☐ Yes ☐ No

If yes, please provide further information:

Do you have any medical conditions

Yes ☐ / No ☐

If YES, please state below:

Asylum and Immigration Act 1996

It is a criminal offence to employ persons whose immigration status prevents them from working in this country. The Act does not affect citizens of the UK, Ireland, European Economic Area and the Commonwealth, provided they have a right of abode in the UK. You will be required to provide evidence prior to appointment of a National Insurance Number, passport or other document on the approved list to satisfy the County Council that the asylum and Immigration Act 1996 is being complied with.

Do you require a work permit?

☐ Yes ☐ No

Confirmation of declaration

(indicate your confirmation by ticking the box to the right of the statement)

Declaration

· I declare that the information given both on this application form and the attached equal opportunities monitoring form is true and correct.

· I understand that any false or misleading information, or omissions of information concerning criminal convictions, may disqualify my application or may render my Contract of Employment, if I am appointed, liable to termination.

Signature:

Date:

Print name:

If form has been completed electronically, please place an ‘x’ in this box to indicate your consent à

☐

Data Protection Act 1998

Karing People Healthcare will only process the information you have provided in this form for the purpose of recruitment and selection and, if you are successful in securing this position, for purposes relating to your employment. Your details will be kept electronically We will not disclose this information about you to outside organisations or third parties unless there is a legal requirement to do so, or for the prevention and detection of fraud.

CONFIDENTIAL: Equal Opportunities in Employment – Monitoring Form

Job applied for

How did you learn of this vacancy?

Surname and initials

16 – 24 years

☐

25 – 34 years

☐

35 – 44 years

☐

45 – 54 years

☐

55 – 64 years

☐

65 years and older

☐

Prefer not to say

☐

A. White

C. Black or Black British

British

☐

Caribbean

☐

Irish

☐

African

☐

Gypsy / Roma

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Any other Black background

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Traveller of Irish Heritage

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Any other White background

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D. Asian or Asian British

Indian

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B. Mixed

Pakistani

☐

White and Black Caribbean

☐

Bangladeshi

☐

White and Asian

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Any other mixed

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E. Other ethnic groups

Chinese

☐

Any other ethnic group (please specify)

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Christian

☐

Buddhist

☐

Hindu

☐

Jewish

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Muslim

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Sikh

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Other religion

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No religion

☐

Prefer not to say

☐

Bisexual

☐

Gay man

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Gay woman / lesbian

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Heterosexual / straight

☐

Other

☐

Prefer not to say

☐

Yes

☐

No

☐

Prefer not to say

☐

Do you consider yourself to be disabled as set out in the Equality Act?

Yes ☐ / No ☐

If YES, please describe your disability.

If you need any assistance to attend or participate in the interview, please give details.