Application Form

Application for the post of: *

Personal Details

National Insurance Number*

Title*

Surname *

First Name(s)*

Previous name (if applicable)

PIN (If applicable)

Home address

Address Line 1*

Address Line 2*

Town/City*

County*

Post code*

Telephone number*

Email Address*

Date of Birth*

Place of Birth*

Nationality*

Do you have a British passport?*

Yes

If not, do you have the right to live and work in the UK? *

Yes

Passport issuing Authority *

Passport expiry date*

Passport Number*

Which of the following documents do you have?

Biometric Resident Permit*

Yes

Number*

Date of Expirt*

Dependent Visa*

Yes

Number*

Date of Expiry*

Student Visa*

Yes

Number*

Date of Expiry*

If student visa, please provide name of educational establishment*

Do you require a Certificate of Sponsorship? *

Yes

Number of Children*

Ages of Children

Name of next of kin*

Relationship*

Address of next of kin

Address Line 1*

Address Line 2*

Town/City*

County*

Post code*

Home telephone number*

Mobile number*

Have you ever worked for or applied to the Heathers Nursing Home before?*

Yes

If yes, give details*

Have you had your Covid-19 vaccines? If yes, please give details of dates:

1st Vaccine*

2nd Vaccine*

Booster Vaccines*

Details of absence from work (excluding holidays) over the last 12 months

Number of days absence*

Number of episodes*

Do you have a current full driving licence*

Yes

Do you own a car?*

Yes

How many miles do you live away from the care home?*

Are you related to any present or former employees of the care home?*

Yes

If yes, give details*

Education and qualifications

Date*

College/ Hospital/ University*

Qualification & Grade*

Professional qualifications

Dates *

College/ Hospital/ University*

Qualification & Grade*

If applicable: UKCC PIN

Renewal date

Qualifications still to be taken

Dates*

Please specify the exam date and level with the subject and School/ College/ University

College/ Hospital/ University*

Subject & Level*

Current or most recent post

Employer*

Job title*

Starting date*

Do you have a leaving date or are you still employed?*

I have a leaving date

I'm still employed

Reason for leaving*

Current Salary/Wage or Finishing Pay*

(This information must be correct as it will be verified)

Employment history

Please include all jobs since leaving education. State most recent position first and include gaps in employment and the reason (eg unemployment, bring up family).**

Start date*

Leaving date*

Employer*

Job Title*

Reason for leaving*

Hobbies and Interests

Please give details of any special interests/hobbies including voluntary work*

References

Please give below the names and addresses of two referees who can provide relevant information regarding your experience and qualifications for this appointment. One should be your present/last employer. Please note that if an employment offer is made to you your referees will be approached without further contact with you for permission.

1st referrer

Name*

Position*

Organisation*

Address

Address Line 1*

Address Line 2*

Town/ City*

County*

Post code*

Home Telephone*

Email*

Is this your current employer?*

Yes

Are they related to you?*

Yes

2nd referrer

Name*

Position*

Organisation*

Address

Address Line 1*

Address Line 2*

Town/ City*

County*

Post code*

Home Telephone*

Email*

Is this your current employer?*

Yes

Are they related to you?*

Yes

Rehabilitation of offenders act

Because of the nature of the work for which you are applying, the post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975. Applicants are not entitled to withhold information about convictions which for any other purposes are spent under the provision of the Act and in the event of employment failure to disclose convictions could result in summary dismissal. Any information given will be confidential and considered only in relation to an application for positions to which this order applies. Note that false declarations may be reported to the Police.

Please give details of any convictions with dates*

I certify that the information given on this form is correct to the best of my knowledge. I understand that any misleading statement or deliberate omission may be sufficient grounds for refusal or termination of employment. This appointment is subject to a satisfactory medical examination and the completion of a supplementary medical questionnaire. I understand that any engagement is subject to the receipt of satisfactory references and Criminal Record Bureau check.*

I agree

Sign Name*

Date*

Additional Information*

Please write briefly why you should be considered for this post.

Declaration

I declare that all the statements are true and complete to the best of my knowledge and belief.

Signature*

Date*

NAME (BLOCK CAPITALS)*

Equal Opportunities Monitoring Form

The information supplied on this form will be used in total confidence and in accordance with current Data Protection legislation. It will help us to ensure that The Haven properly monitors and conforms with its policies relating to the equality of opportunity. Information will be used for monitoring and for no other purpose. Our committed aim is to allow our staff to develop their skills and realise their maximum potential as individuals without any wish on the part of The Haven to limit their opportunities. Please tick the relevant box or boxes.

Please specify:*

Are you:*

Male

Female

Please indicate your age in the ranges below*

Do you consider you have a disability*

Yes

IF YES, please indicate the nature of the disability.*

Application Form

Striving for Excellence