APPLICATION FORM

Applicant’s First Name

Applicant’s Middle Name

Applicant’s Surname:

Position Applied SUPPORT WORKER

Date of Application 18/07/2023

Authorised By
Management Signature

Start Date: 18/07/2022

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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 SUPPORT WORKER Post HCA
applied for reference no
Last name: Title (Please MR
specify) e.g.
Miss/Ms/Mrs/
Mr
Middle name National SL141897B
Insurance
Number
First Date of Birth 08/03/1990
name(s):
Previous Evening
Surname(s) telephone
(if applicable number
Do you Mobile 07883110293
require a YES NO number:
work permit
to enable
you to work
in the UK?
Address for 256,HORNS ROAD,BARKINGSIDE
corresponde
nce
Postcode IG6 1BS

Email [email protected]
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.

Yes No x Not applicable for this role

Yes No x Not applicable for this role

I have a learning licence.

Education and Training

Date Date to Secondary School Qualifications
From Month/ Year /College/University/ Training
Month/ Year Organization

01/Aug/ 17/Aug/2018 NIED EDUCATION COUNCIL DIPLOMA IN HOME CARE

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 Date Date to Secondary School Qualifications
From Month/ Year /College/University/ Training
Month/ Year Organization

2017 NEW DELHI AND WORKER

01/April/ 1/April/2015 Kurukshetra Bachelor of Arts.
2012 University,Kurukshetra
1/March/ 31/March/ Paradise senior secondary School senior Certificate
2006 2007 School,babain

Next of Kin: Relationship to Day Phone: Evening Phone:

the Applicant

Address

Membership of Professional Bodies (Nursing and Midwifery Council, General Social Care Council or
Other)
Name: None Membership/Status

Renewal date Number

Employment Experience
Please give details of your present or most recent employment/voluntary work first and work backwards. Include all
periods of unemployment; travel etc, in the space provided so there are no gaps in the record. (If you have
additional previous employment, please give details on a separate sheet using the same format).

Date: from Date: to Employer’s name and Job titles and brief Reason for
(month/year) (month/year) address and nature of description of duties leaving
business

01/12/2018 20/03//2023 As a care taker Left for the

Physiotherapy Friend United Kingdom

Gaps in your employment

Please provide information of any gaps in employment
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(Verification of employment gaps will be required if an offer of employment is made)

From (month/year) To (month/year) Reason/s for the gap

References
Please ensure that you give a minimum of two references, which cover at least the last five years of your
employment. The first of your references must be your present employer and your relevant line manager. If
you are unemployed, this should be your last employer, or if this is your first job, your head-teacher or college tutor.
Please note that we reserve the right to take up references in respect of any previous employment paid or unpaid,
without further notification to you.

Current employer /
Organisation
Name of employer: PHYSIOTHERAPY FRIEND

Job title: Support Worker

Organization address (in full): PHYSIOTHERAPY FRIEND,NEAR TANNU GYM,

MULLANA
Postcode 133203

Tel No.: 00919729552360

Email: [email protected]

In what capacity do you know them? POSITIVE STAFF.

Previous employer/Character
Reference
First Name / surname: Abhay singh

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 Job title: (if Applicable) Care worker

Organization address (in full): Physiotherapy Friend

Postcode 133203

Tel No.: 9953590203

Email: [email protected]

In what capacity do you know them? Good atmosphare.

Previous employer/Character
Reference
First Name / surname: Rajat kumar

Job title: (if Applicable) Support worker

Organization address (in full): Physiotherapy friend

Postcode 133203

Tel No.: 9068600528

Fax No.:

Email: [email protected]

In what capacity do you know them? Postive staff.

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?

Yes x No

*** Please note that it is our policy to obtain references prior to interview for any post in a residential
establishment. For all posts, we will ask your referees for comments on your suitability for the post and for
employment referees request details on attendance, sickness levels and salary.

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.

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 Yes No x

If yes please give details

b) 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 No x

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)

Experienced
I have experience in support worker.

Skills
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I am caring and courageous in nature and passionate about caring for people.

Qualifications
Diploma in home care and worker.

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 HALIFAX BANK
the Society’s Bank details)

Bank Branch: HALIFAX BANK,ILFORD

Sort Code: 11-04-00

Account Holder’s Name: ROHIT KUMAR

*Account No: 17595264

*if your accounts is with Lloyds TSB Bank please add a
leading zero to your account number

Applicant Declaration
Rehabilitation of offenders Act (1974)

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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 No X

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 X
applicants Yes No
Are you subject to
any current
outstanding
disciplinary action or
legal proceedings?

If yes please give details below

Section B-General X
posts - Criminal Yes No
convictions
Have you ever been
convicted of a
criminal offence
(‘unspent’ only)?
If yes, please give
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us details of all
offences, penalties
and dates on the
page marked
Criminal
Record/Disqualificati
on/Other in this
application form.

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 - X
Criminal record Yes No
Have you ever been
convicted of a
criminal offence or
cautioned?
Reprimanded or
given a final warning
by the police (‘spent’
or ‘unspent’)? If
yes, please give
details of all
offences, penalties
and dates on the
page marked
Criminal
Record/Disqualificati
on/Other in this
application form.
If yes please give
details below

Regulatory body X
sanctions Yes No
Are you subject to
any sanctions
imposed by a
regulatory body
e.g. GSCC, NISCC,
SCCC, CCW, GTC,
RCN?
If yes please give
details below

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Disqualification/
Other in this Yes No X
application form.
Disqualification
from working with
children or
vulnerable adults
Are you disqualified
from working with
children or
vulnerable adults?
If yes please give
details below

Section D- X
Enhanced
Disclosures only Yes No
Are you aware of
any police enquiries
undertaken
following allegations
made against you
that may have a
bearing on your
suitability for the
post?
If yes please give
details below

Criminal Records/ Disqualification/ Other

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

Declaration of Health

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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?
Description of Yes No Details / Dates
illness
1 COVID-19 X
vaccination
2 Cardiac/Vascular X
Illness
3 Eye Disease/ X
Inquiry or Defect
of Vision Not
Corrected by
Lenses
4 Asthma X
5 Tuberculosis X
6 Diabetes X
7 Epilepsy, Frequent X
Fainting Attacks
8 Chicken Pox X
9 Any Degree of X
hearing Loss
10 Hepatitis X
11 Back pain, X
Sciatica
12 Do you have any X
deformities, which
effect
movements?
13 Are you receiving X
any medication
from a doctor?
14 Have ever been X
treated for any
other serious
illness / operation
15 Are you a X
registered disable
person?
16 Mental Illness X
17 I believe that I am X
medically fit to
carry out the
duties of the
position I have
applied for
18 Are there any X
reasonable
adjustments that
an Employer
should make to
enable you to
work?
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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: Immunised
Poliomyelitis Anti-body level: Immunised
Varicella Anti-body level: Immunised
Tetanus Anti-body level: Immunised
Hepatitis B Anti-body level: Immunised
Any Other Meningitis Immunised

General Practitioner’s Name:

Address or Occupational Health Department:

I declare that all the foregoing statements are true and

complete to the best of my knowledge and belief.
Signed: ROHIT KUMAR Date: 01/09/2022

Availability form
Hours of Work

Full time X Part time

Type of work
Care Homes X Residential X Day Care
Homes Centre
Domestic Kitchen Domiciliary X
Assistant Care
Hospital Cook Live in Care X

Hours Available
Shift Time Other times Please
specify

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 Long day X 8:00 am to 8:00 am

Morning Shift X 7am to 2:30 pm

Afternoon Shift X 2 pm to 9:30 pm

Night Shift X 8:00 pm to 8:00 am

Other specify 9:00 am to 11:00

Various Shifts are

Available please Enquire

Declaration- To be completed by all applicants

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.

Signature ROHIT KUMAR

Date 01-09-2023

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