Application Form

Step 1 of 11

Applicant’s First Name

Applicant’s Middle Name

Applicant’s Surname:

Position Applied

Date of Application

MM slash DD slash YYYY

Authorised By

Management Signature

Start Date:

MM slash DD slash YYYY

Application Form - Confidential The information supplied on this application form will be used to evaluate your suitability for employment. Please read the guidance notes before completing the forms. Once completed, please return the forms to us. If applying by email, please remember to quote the relevant job reference in the subject line of your email.

Personal information

Position applied for

Post reference no

Title

First Name

Middle Name

Last Name

Previous Surname(s) (if applicable

National Insurance Number

Date of Birth

MM slash DD slash YYYY

Evening telephone number

Do you require a work permit to enable you to work in the UK?

Address for correspondence

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Post Code

Email Address

Please answer the following question if the job/person profile for the job requires this. Please click or put x on the box that applies to you.

Do you hold a current full driving license?

Yes

Not applicable for this role

If yes is it a clean driving license?

Yes

Not applicable for this role

If no please give details

Education and Training

Date From Month/ Year

Date to Month/ Year

Secondary School /College/University/ Training Organization

Qualifications

Date From Month/ Year

Date to Month/ Year

Secondary School /College/University/ Training Organization

Qualifications

Next of Kin:

Relationship to the Applicant

Day Phone:

Evening Phone:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Membership of Professional Bodies (Nursing and Midwifery Council, General Social Care Council or Other)

Name

Membership/Status

Renewal date

MM slash DD slash YYYY

Number

Date: from (month/year)

MM slash DD slash YYYY

Date: to (month/year)

MM slash DD slash YYYY

Employer’s name and address and nature of business

Job titles and brief description of duties

Reason for leaving

Date: from (month/year)

MM slash DD slash YYYY

Date: to (month/year)

MM slash DD slash YYYY

Employer’s name and address and nature of business

Job titles and brief description of duties

Reason for leaving

From (month/year)

MM slash DD slash YYYY

To (month/year)

MM slash DD slash YYYY

Reason/s for the gap

Current employer / Organisation

Name of employer:

Job title:

Organization address (in full):

Postcode

Tel No.:

In what capacity do you know them?

First Name / surname:

Job title: (if Applicable)

Organization address (in full):

Postcode

Tel No.:

In what capacity do you know them?

First Name / surname:

Job title: (if Applicable)

Organization address (in full):

Postcode:

Tel No.:

Fax No.:

In what capacity do you know them?

Please click or put x on the box that applies to you. Can we contact your current employer prior to any conditional offer of employment?

Yess

Notice Period If appointed how soon you could join us: Disability has a policy of interviewing applicants who have a disability and who meet the essential short-listing criteria. To ensure that this happens, please complete the following: a) The Equality Act 2010 defines disability as' a physical or mental impairment which has a substantial and long-term adverse effect on the ability to carry out normal day-to-day activities'. Do you consider yourself to have or have had a disability?

Please click on the box that applies to you.

Yes

If yes please give details

If the answer to the above is yes, are there any reasonable adjustments that need to be made, should you progress beyond this stage? Please click or put X on the box that applies to you.

Yes

If yes please give details

Relevant Experience

Please tell us how your experience, skills and qualifications meet the requirements of the person and job profiles. Please focus your response on the abilities and/or competencies required for the role giving evidence of your experience to date (maximum of 2 A4 sheets). The information you provide will be the basis for short-listing and you may find it useful to refer to the guidance notes attached before completing this section.

(Please use continuation sheet)

Bank/ Building Society Details

Surname:

Forenames

Branch:

Payroll no:

Private/Domestic Payroll No:

TO BE COMPLETED BY EMPLOYEE

I authorized to pay my weekly/ Monthly earnings direct into the Bank/Building society Account whose details follow. I will notify you in writing of any change to these details

Building Society Roll No: (if applicable)

Bank Name: (if a Building Society Account please give the Society’s Bank details)

Bank Branch:

Sort Code:

Account Holder’s Name:

*Account No: *if your accounts is with Lloyds TSB Bank please add a leading zero to your account number

Applicant Declaration

Rehabilitation of offenders Act (1974)

Because of the nature of the work for which you are applying, the provisions of Section 4(2) of the Rehabilitation of Offenders Act (1974) do not apply by virtue of the Rehabilitation of Offenders Act (1974) (exceptions) Order 1975. Applicants are therefore required to give information about convictions, which for other purposes are '‘pent’ under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the Order applies.

Please click on the box that applies to you.

Have you at any time been convicted of an offence? (y/n)

Yes

IF YES, PLEASE GIVE DETAILS BELOW: -

I declare that the information given above is, to the best of my knowledge, true, I am permitted to work in the UK. I have read, understood and agree to the conditions of work for temporary nurses and carers, of which I have been given a copy. I understand that my registration is subject to the receipt of at least two satisfactory references and a satisfactory result after checking with the Department of Health and/or Police records. I undertake to inform EMEZZIONS CARE. should I be convicted of an offence in the future. I undertake to inform EMEZZIONS CARE immediately if I am engaged through introduction, including the offer of permanent employment following a temporary assignment. I also acknowledge that this information may form the basis of a computerized personnel system to which I will have access as determined by the Data Protection Act 1984. I agree to respect the confidentiality of Service Users and any other information I may have access to all times. Your registration with EMEZZIONS CARE can be terminated at any time following unsatisfactory work reports.

Criminal Records, Disqualification & Declaration

Please refer to covering letter before completing section B, C or D below

Section A- All applicants.Are you subject to any current outstanding disciplinary action or legal proceedings?

Yes

If yes please give details below

Section B-General posts - Criminal convictions Have you ever been convicted of a criminal offence (‘unspent’ only)? If yes, please give us details of all offences, penalties and dates on the page marked Criminal Record/Disqualification/Other in this application form.

Yes

If yes, please give us details of all offences, penalties and dates on the page marked Criminal Record/Disqualification/Other in this application form.

Section C - Criminal record Have you ever been convicted of a criminal offence or cautioned? Reprimanded or given a final warning by the police (‘spent’ or ‘unspent’)?

Yes

If yes, please give details of all offences, penalties and dates on the page marked Criminal Record/Disqualification/Other in this application form. If yes please give details below

Regulatory body sanctions Are you subject to any sanctions imposed by a regulatory body e.g. GSCC, NISCC, SCCC, CCW, GTC, RCN?

Yes

If yes please give details below

Disqualification/Other in this application form. Disqualification from working with children or vulnerable adults Are you disqualified from working with children or vulnerable adults?

Yes

If yes please give details below

Section D- Enhanced Disclosures only Are you aware of any police enquiries undertaken following allegations made against you that may have a bearing on your suitability for the post?

Yes

Criminal Records/ Disqualification/ Other

Untitled

Details of Declaration of Criminal Convictions (Please give details below):

Declaration of Health

Please answer the following questions by ticking the appropriate YES/NO box. If the answer to any questions is YES, then give details in the space provided or on the back of this form. It is your responsibility to inform us immediately if any of the following information changes. Have you ever had in your life, including childhood, any of the following?

COVID-19 vaccination

Yes

Details / Dates

Cardiac/Vascular Illness

Yes

Details / Dates

Eye Disease/ Inquiry or Defect of Vision Not Corrected by Lenses

Yes

Details / Dates

Asthma

Yes

Details / Dates

Tuberculosis

Yes

Details / Dates

Diabetes

Yes

Details / Dates

Epilepsy, Frequent Fainting Attacks

Yes

Details / Dates

Chicken Pox

Yes

Details / Dates

Any Degree of hearing Loss

Yes

Details / Dates

Hepatitis

Yes

Details / Dates

Back pain, Sciatica

Yes

Details / Dates

Do you have any deformities, which effect movements?

Yes

Details / Dates

Are you receiving any medication from a doctor?

Yes

Details / Dates

Have ever been treated for any other serious illness / operation

Yes

Details / Dates

Are you a registered disable person?

Yes

Details / Dates

Mental Illness

Yes

Details / Dates

I believe that I am medically fit to carry out the duties of the position I have applied for

Yes

Details / Dates

Are there any reasonable adjustments that an Employer should make to enable you to work?

Yes

Details / Dates

Please give details of last immunization or vaccination for

Tuberculosis (We will require a statement of evidence regarding TB immunity i.e. Heaf / Mantoux status)

Rubella (German Measles) : Anti-body level:

Poliomyelitis : Anti-body level:

Varicella : Anti-body level:

Tetanus : Anti-body level:

Hepatitis B : Anti-body level:

Any Other : Meningitis

General Practitioner’s Name:

Address or Occupational Health Department:

Consent

I declare that all the foregoing statements are true and complete to the best of my knowledge and belief. I hereby given EMEZZIONS CARE permission to contact my General Practitioner to obtain further information should it be required.

Date

MM slash DD slash YYYY

Availability form

Hours of Work

Full time

Part time

Type of work

Care Homes

Residential Homes

Day Care Centre

Domestic

Kitchen Assistant

Domiciliary Care

Hospital

Cook

Live in Care

Hours Available

Long day

8:00 am to 8:00 am

Other times Please specify

Morning Shift

7am to 2:30 pm

Other times Please specify

Afternoon Shift

2 pm to 9:30 pm

Other times Please specify

Night Shift

8:00 pm to 8:00 am

Other times Please specify

Other specify

9:00 am to 11:00

Various Shifts are Available please Enquire

Declaration- To be completed by all applicants

Consent

I confirm that the information I have given is correct and complete and that any false statements or omissions may render me liable to dismissal without notice or in some instances, referral to the police. I understand and agree that data contained in the application form will be used and processed for recruitment purposes. I also understand and agree that should I become an employee; the information will also be used for employment related purposes. I agree to EMEZZIONS CARE holding and processing this information

Date

MM slash DD slash YYYY

Application Form