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?*
If not, do you have the right to live and work in the UK? *
Passport issuing Authority *
Passport expiry date*
Passport Number*
Which of the following documents do you have?
Biometric Resident Permit*
Number*
Date of Expirt*
Dependent Visa*
Number*
Date of Expiry*
Student Visa*
Number*
Date of Expiry*
If student visa, please provide name of educational establishment*
Do you require a Certificate of Sponsorship? *
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?*
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*
Do you own a car?*
How many miles do you live away from the care home?*
Are you related to any present or former employees of the care home?*
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?*
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?*
Are they related to you?*
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?*
Are they related to you?*
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.*
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.
Would you describe your ethnic origin as:*
Please specify:*
Are you:*
Please indicate your age in the ranges below*
Do you consider you have a disability*
IF YES, please indicate the nature of the disability.*