Homecare Solutions Ltd Form No: 03-1-200 JOB

APPLICATION

POSITION APPLIED FOR: Job Reference:

Please complete this Application Form in block capitals in black or blue ink.
Should you require more space please continue on a separate sheet clearly marking the section to which it relates.

A: PERSONAL DETAILS
Title (Mr/Mrs/Miss/Ms/other): ______ Surname: _____________________ Forename(s): ________________________________

Address: ______________________________________________________________________Postcode: ___________________

Telephone: Private: _____________________ Business: ______________________ Mobile: _________________________

E-mal address: _______________________________________________________ This address is: Personal ____ Work ____

Date of Birth: _____________ Next of Kin:__________________ Contact number:________________

N.I. number: _____________________ Do you need a permit to work in the UK? YES:____ NO: ____

B: DRIVING RECORD
Do you have regular use of a car? YES: ___ NO: ___ Make / model / year:_____________________________________

Current Driving Licence: PROVISIONAL: ____ FULL: ____ PSV:____ NONE: ____

Driving Licence valid from: ______________ to: _______________

Details of current endorsements : ______________________________________________________________________________

___________________________________________________________________________________________________________

Do you have any driving-related prosecutions / fixed penalties / endorsements or similar currently pending? YES:__ NO: __

If “YES” please provide brief details: __________________________________________________________________________

Have you ever been disqualified from driving? YES: ___ NO: ___

If "YES" please provide brief details: ___________________________________________________________________________

Have you ever had insurance refused? YES: ___ NO: ___

If "YES" please provide brief details: ___________________________________________________________________________

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Homecare Solutions Ltd Form No: 03-1-200 JOB
APPLICATION

C: EDUCATION & PROFESSIONAL TRAINING (from year 11)

Education Centre (school, college etc) DATES Qualifications gained
from to
1. Secondary Education (secondary school)

2. Higher Education (university / college / polytechnic)

3. Further Education (Professional Training)

4. Membership of Professional Organisations

D: LANGUAGES
Languages (other than English) : __________________ SPOKEN / FLUENT / WRITTEN / READ
: __________________ SPOKEN / FLUENT / WRITTEN / READ
: __________________ SPOKEN / FLUENT / WRITTEN / READ

E: PERSONAL DBS CERTIFICATES

If the position you are applying for (whether paid or voluntary) is listed in Schedule 1, Part II of the Rehabilitation of Offenders Act
(Exceptions) Order 1975, we are entitled to ask Exempted Questions as defined by Section 113(5) of the Police Act 1997 about you.
We are required to check a DBS Certificate in relation to any person who is a Care Manager or Care Worker. If your application is
successful and before your appointment is confirmed, you will be required to submit a personal current and valid DBS Certificate for
our inspection.

Having a criminal record will not necessarily bar you from working with us. This will depend upon the nature of the position and the
circumstances and background of your offences. We observe the “Code of Practice for Registered Persons and Other Recipients of
Disclosure Information” published through the Disclosure & Barring Service on behalf of the Home Office, and we will provide you
with a copy of it upon request.

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Homecare Solutions Ltd Form No: 03-1-200 JOB
APPLICATION

F: EMPLOYMENT HISTORY
Please provide details of all employment, beginning with your present or most recent job first

DATES Employer Salary Position(s) Reason for leaving

held
from to

G: VOLUNTARY & COMMUNITY WORK EXPERIENCE

DATES Organisation Position(s) held Duties
from to

H: JOB FLEXIBILITY

Prepared to work: FULL-TIME: ____ PART-TIME: ____ SHIFTS: ____

If PART-TIME please indicate preferred hours: _________________________________________________

Details of any other work which you will continue to undertake if you are offered this Job Position:

Please provide details of any outstanding holidays to be taken:

AVAILABLE TO TAKE UP EMPLOYMENT FROM: _______________________________________________

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Homecare Solutions Ltd Form No: 03-1-200 JOB
APPLICATION
I: REFERENCES

Please provide details of 2 referees who we may approach with regards to this Job Application. These
referees must not be members of your family, and one must be your present or most recent employer:

1. Name: _______________________________________________________________________

Address: _____________________________________________________________________

_____________________________________________________________________________

Telephone Number: _______________________________________

Occupation: _________________________________________________________________

2. Name: ______________________________________________________________________

Address: ____________________________________________________________________

____________________________________________________________________________

Telephone Number: _______________________________________

Occupation: _________________________________________________________________

May we contact your referees prior to making a job offer? YES: ___ NO: ___

J: DECLARATION BY JOB APPLICANT

ANY PERSON, UPON SUBSEQUENT EMPLOYMENT, THAT IS FOUND TO HAVE KNOWINGLY SUPPLIED FALSE OR
MISLEADING INFORMATION, OR HAS DELIBERATELY WITHHELD RELEVANT INFORMATION, MAY BE SUBJECT TO
DISCIPLINARY PROCEEDINGS WHICH MAY RESULT IN DISMISSAL

I have read and understood the information supplied to me in relation to this Job Position, and the information requested in this Job
Application Form. I confirm that all information supplied by me is true and correct to the best of my beliefs.

I give the prospective employer the right to follow up all references and to make any other job-related enquiries as may be deemed
necessary.

Signature: _____________________________ Date: ______________________

(____________________) IS AN EQUAL OPPORTUNITIES EMPLOYER

The sole criterion for selection of applicants will be suitability for the Job Position, regardless of gender, background, culture, ethnic denomination,
religious affiliation, marital status or disability.

Data Protection Act, 1998: Your signature on this document gives us the right, under the Data Protection Act, 1998 to process the information you
have given, including data of a sensitive nature, relating to your application for employment. Any processing of the data by us will be in accordance
with our Policy and the processing principles set out in the Act. Application forms of unsuccessful candidates will be destroyed after 6 months in
accordance with our Record-keeping Policy.

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