APPLICATION FORM

Your Trusted Healthcare Staffing Partner!

APPLICATION FORM

The recruitment process within this organization has a minimum of two stages.

The completion of this application form is part of stage one. This application will be reviewed, and a decision made as to whether to proceed to stage two, the interview, based on this information.

PLEASE COMPLETE FULLY

Surname

First Name

Nationality

National Insurance Number

Position Applied For

Approx. number of hours wanted:

What training and previous experience do you have in this role

Proof of training and experience

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How will your training and previous experience be essential to this this role?

Full time / part time

(please circle which you want to work, or delete as appropriate)

Address: Full addresses covering the five years up to the application date must be

supplied. If necessary, use another sheet of paper.

Current Address

Date when you moved to address on the left

Previous Address

Date moved to address on the left

Last date at the address

Telephone number (home and/or mobile):

Email address

Do you have access to a car?:

Yes

Clean current driving license?

Yes

How long has license been held?

Any Endorsements?: Yes/No

Yes

Details of endorsements if any:

EDUCATION

Education Information

School/ College/ University	Examinations Passed/Qualifications gained	Enter Date (dd/mm/yyyy)

TRAINING HISTORY/PROFESSIONAL STATUS

TRAINING HISTORY/PROFESSIONAL STATUS

Training Location/ College/ University	Examinations Passed/Qualifications gained	Enter Date (dd/mm/yyyy)

SHORT COURSES ATTENDED

Training Location	Subject	Enter Date (dd/mm/yyyy)

FULL EMPLOYMENT HISTORY

State the reasons for any breaks in employment. Use a separate sheet if required, please sign that sheet and attach.

Employment Information

Start Date – End Date	Name and address of Employer starting with the most recent	Position Held

HEALTH DETAILS

Do you have any mental or physical disability or illness (currently or recurring) which is relevant to the post for which you are applying? Yes / No

Yes

If yes, please give details:

What adjustments (if any) need to be made to the working environment to accommodate your disability?

Please give details of all absences from work in the last 12 months, except holidays

Please give details of any illnesses/accidents/injuries in the last 2 years

GP’s Name

Tel No

Address

NEXT OF KIN

Full Name

Relationship

Tel No

Address

CAPACITY TO WORK IN THE UK

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?

Yes

If yes, please provide details

If you are successful in the application, would you require a work permit prior to taking up employment?

Yes

Note: Minimum age; legislation dictates that care workers in general must be 18 years old or older, and Carers working with people with learning disabilities must be 21 or older. Please inform your interviewer immediately if you do not meet these specifications.

Proof of identity (e.g. birth certificate, Passport etc.)

Choose Your File

REFEREES

You must provide references from your two most recent employers. All will be contacted, therefore please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.

Current or most recent employer

Name:

Referees job title:

Address:

Post Code:

Tel No:

Email:

Previous employer to the one above

Name:

Referees job title:

Address:

Post Code:

Tel No:

Email:

CRIMINAL RECORD

Workers in this establishment are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warning and cautions.

You will not be eligible for work in a care setting if you are on the ISA Register(s).

Do you have any criminal convictions, warnings or cautions, even if “spent”: Yes/No

Yes

If yes, please give details:

Notice period with existing employer:

Please indicate where you found out about the vacancy:

SIGNATURE and DECLARATION

IMPORTANT – READ BEFORE SIGNING

I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.

I understand that I cannot be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise the organisation to request a DBS Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred Care workers, or withdrawal of any registration required by my employment status.

Date:

EQUAL OPPORTUNITIES

MaxLife Care Ltd is an equal opportunities employer. Selection of applicants will be based on suitability for the job regardless of ethnic background, sexual orientation, age, disability, gender, culture, marital status, religion, or belief.

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Full Time
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