Job Application

Personal Information

Title:

Full Name:

Position Applied For:

Address:

Email:

Mobile Phone:

Home Phone:

Do You Require Permission To Work In The UK?

Yes

Do You Have Current Permit To Work?

Yes

Emergency Contact Details

Name:

Phone Number:

Relationship:

References

We require at least two references covering the last two years of employment or more.
If you have had less than two employers in the last two years, you can give a character reference who must have known you for at least three years, known you in a professional or academic capacity and is not a relative.

First Professional Reference

Name:

Organisation:

Position:

Work Number:

Email:

Second Professional Reference

Name:

Organisation:

Position:

Work Number:

Email:

Third Professional Reference (If applicable)

Name:

Organisation:

Position:

Work Number:

Email:

Character Reference

Name:

How long have you known this person:

Phone Number:

Email:

Full Employment History

Employment 1

Organisation:

Position:

Address:

Reason For Leaving:

Outline of Roles and Responsibilities:

Employment 2

Organisation:

Position:

Address:

Reason For Leaving:

Outline of Roles and Responsibilities:

Employment 3

Organisation:

Position:

Address:

Reason For Leaving:

Outline of Roles and Responsibilities:

If you have any gaps in your employment, please note dates and reasons

Education and Training

Organisation 1:

Subject:

Date From (DD/MM/YY):

Date To (DD/MM/YY):

Address:

Details of your subject, course, training and qualifications:

Organisation 2:

Subject:

Date From (DD/MM/YY):

Date To (DD/MM/YY):

Address:

Details of your subject, course, training and qualifications:

Organisation 3:

Subject:

Date From (DD/MM/YY):

Date To (DD/MM/YY):

Address:

Details of your subject, course, training and qualifications:

Experience and Practical Skills

Please summarise the job skills you've acquired:

Please detail any specialist care training you've received:

Which of your personal qualities most suit you to the job:

Please detail the client groups and conditions you have experience of working with:

General

Do you have a current full UK driving license?

Yes

Do you have access to a vehicle for work?

Yes

Do you have appropriate insurance cover for vehicles used at work?

Yes

Which of the following groups would you prefer to work with:

Which areas/boroughs would you prefer working in:

Please indicate your availability (i.e days, nights, weekdays, weekend or all):

Date you could start work (DD/MM/YY):

Do you have any particular interests, hobbies or skills you would like to mention:

Declarations

Employment Declaration

It is a condition of your registration with us that you declare any employment you are engaged in. Please provide employment details:

Full Name:

Signature

Health Declaration

I CAN CONFIRM THAT I AM FIT AND WELL ABLE PHYSICALLY AND MENTALLY TO CARRY OUT THE ROLE OF COMPLEX CARE WORKER TO VULNERABLE INDIVIDUALS TO THE KEEP THEM SAFE AND NOT PUT THEM OR MYSELF IN ANY DANGER OR HARM DUE TO MY HEALTH.
I give permission for my doctor to be contacted, if necessary, to confirm that I am able to undertake the duties with out risk to my health, safety and welfare whilst, or prior to, working for this organisation.

Full Name:

Signature

Rehabilitation of Offenders Act, 1974

We aim to provide care workers to enable people who use services to live within their community as independently as possible including care to vulnerable people. It is therefore essential that you declare whether you have been convicted of any criminal offences. The post to which you are applying is exempt from the provision of section 4 (2) of the Rehabilitation of Offenders Act, 1974 by virtue of the Rehabilitation of Offenders. Act 1974 (Exemption) order of 1975. It is therefore a necessity for you to supply all information regarding convictions, which for other purposes would be spent under the provisions of the act. If you are accepted for the post of your application, failure to declare such convictions could result in disciplinary action, including dismissal.

If convictions have been recorded against you, this does not necessarily prevent you for consideration for the post, but it does depend upon what those convictions are for.

In addition to this declaration, successful candidates will have to give their authority for a National Police check to be carried out if the nature of the work offered to them warrants it. You may also be required to obtain a Prosecution/Conviction History from your local Police Station, which is obtainable under the provisions of section 21 of the Data Protection Act, 1984.

Considering the above, please answer the questions below:

Have you ever been convicted of a criminal offence, been cautioned or bound over?

Have you ever been involved in any issues regarding the safeguarding of children or vulnerable adults?

If you have said yes to either question you may supply as much information in the boxes above at your own discretion. Please note, your application is confidential and all information will be treated in the strictest manner.

I declare that I have no convictions, cautions, bind-overs or issues regarding the safeguarding of children or vulnerable adults and have no police or court proceedings pending as of this date. I further declare that I will inform Integral Care of any convictions, cautions, bind-overs or issues regarding the safeguarding of children or vulnerable adults that I receive in the future.

Signature

Equal Opportunities

We are committed to achieving Equal Opportunities and welcomes applications from all.

Personal Details:

Title:

Full Name:

Position Applied For:

Address:

Email:

Mobile Phone:

Home Phone:

Do You Require Permission To Work In The UK?

Yes

Do You Have Current Permit To Work?

Yes

Do You Have Consider Yourself To Have A Disability?

Yes

If ‘Yes’, please give details:

The Working Time Regulations 1998 state that a worker's average working time shall not exceed 48 hours per week on average over a 17-week period, unless the worker agrees in writing that the limit shall not apply. You have indicated your agreement to work in excess of 48 hours per week. Please confirm this by signing the declaration below. We are required to retain this form to allow inspection by the enforcing authority. I agree to work, when necessary, in excess of 48 hours per week. I understand that I may terminate this agreement at any time subject to giving four weeks’ notice in writing.

Please Tick

Authorisation for CRB Disclosure to be retained on file

In accordance with the CRB policy of Integral Care, I authorise Integral Care to retain and make available a copy of my CRB disclosure and related information to a third-party stakeholder.

Please Tick

Statement

I confirm the information given in this form is correct and understand it will be used in the selection process. I also understand that misleading statements may be sufficient grounds for the withdrawal of any offer of employment.

Full Name:

Signature:

Date Signed (DD/MM/YY):

The contents of this form will be confidential and will not be revealed to anyone else without your written consent.

The Management of Health and Safety at Work Regulations 1999 require employers to assess the capability of employees to undertake tasks that they are required to do.

The Work Time directive 1998 require employer to carry out health surveillance on night workers. This form allows this organisation to carry this out. Answering yes to any of the questions on this form will not automatically exclude you from our employment but will require your permission to contact your GP for further information. If in the future it is shown that you have failed to disclose existing or pre-existing conditions then the Company will not accept responsibility in the event if this being a factor if any future claim should ever arise against the company You should also understand that failure to declare correct information may be cause for dismissal.