Working With Us Application FormPlease enable JavaScript in your browser to complete this form.1Personal Details2Education3Previous Employment4Formal Warnings5Current Training6References7Equal Opportunities Monitoring8Health QuestionnairePosition Applied For *Position Applied ForSupport WorkerPersonal DetailsSurname *First names *Previous NamesAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeHome Telephone No. *Work Telephone No. *Mobile No. *National Insurance Number *Immigration DetailsAre you a citizen of the EU? *YesNoDo you need a work permit? *YesNoCurrent driving licence? *YesNoDo you have a car for work use? *YesNoNext1. School/Further Education/Higher EducationSchools/FE/HE attended *Examination Grade *Year Obtained *2. School/Further Education/Higher EducationSchools/FE/HE attendedExamination GradeYear Obtained3. School/Further Education/Higher EducationSchools/FE/HE attendedExamination GradeYear ObtainedPreviousNextA full employment history must be detailed beginning with your current employment and covering all reasons for gaps in any given year.Most Recent/Last EmploymentStart Date *End Date *Employer’s name *Employer’s Phone *Employer's Email *Position Held *Salary & Benefits *Reason for leaving *Employment prior to the aboveStart DateEnd DateEmployer’s nameEmployer’s PhoneEmployer's Email AddressPosition HeldSalary & BenefitsReason for leavingEmployment prior to the aboveStart DateEnd DateEmployer’s nameEmployer’s PhoneEmployer's Email Address *Position HeldSalary & BenefitsReason for leavingPreviousNextPlease detail any disciplinary action within the previous 3 years, including any current, “live” formal warnings *REHABILITATION OF OFFENDERS ACT 1974 – NOTICE TO OFFENDERS Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) The amendments to the Exceptions Order 1975 (2013) provide that certain convictions and cautions are protected and are not subject to disclosure to employers and cannot be taken into account Do you have any convictions to disclose? *YesNoAny information about convictions, cautions, reprimands or final warnings. This information will be treated as confidential and will not necessarily preclude you from employment. *Declaration. Failure to declare or the falsification of any of the above details will result in the withdrawal of any job offer. *I declare that the above details are not falsified. Statement of your personal qualities and any experiences which is relevant to the post *PreviousNextPlease give details of any mandatory training courses completed, along with dates completed and expiry dates.CURRENT TRAININGMoving and HandlingDate CompletedExpiry DateCURRENT TRAININGSafeguarding AdultsDate CompletedExpiry DateCURRENT TRAININGSafeguarding ChildrenDate CompletedExpiry DateCURRENT TRAININGInfection ControlDate CompletedExpiry DateCURRENT TRAININGHealth and Safety Date CompletedExpiry DateCURRENT TRAININGFire Safety Date CompletedExpiry DateCURRENT TRAINING Basic Life Support / Resuscitation Date CompletedExpiry DateCURRENT TRAININGPreventing RadicalisationDate CompletedExpiry DateCURRENT TRAININGConflict Resolution Date CompletedExpiry DateCURRENT TRAININGData Security AwarenessDate CompletedExpiry DateCURRENT TRAININGEquality, Diversity and Human Rights Date CompletedExpiry DateDetails about any additional courses you have undertaken relevant to Health and Social Care. (For example PMVA, PBS or ProAct Scip)PreviousNextPlease give the name and address of two referees, one of whom must be your current or most recent previous employer. References from relatives or friends are not accepted.1. ReferenceReferral Name *Status *Referral's Email *Address *Telephone Number *2. ReferenceReferral Name *Status *Referral's Email *Address *Telephone Number *3. ReferenceReferral NameReferral's EmailStatusAddressTelephone NumberThis organisation seeks to work in a flexible and family friendly manner with its staff, however unsocial hours are part and parcel of a quality care service. Weekend working is a requirement for all staff, the frequency of which will be determined at interview.Please indicate holiday dates if already bookedPeriod of notice required in present postEarliest start date *PreviousNextThis section of the application will be detached and used for monitoring purposes only. Our organisation recognises and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect in line with the Equality Act 2010 legislation. We welcome applications from all sections of the community.Date of Birth *Gender *MaleFemaleI do not wish to disclose thisRace Relations (Amendment) 2000I would describe my ethnic origin as (please tick):Asian or Asian BritishBangladeshiIndianPakistaniAny other Asian backgroundBlack or Black BritishAfricanCaribbeanAny other Black backgroundMixed RacedWhite & AsianWhite & Black AfricanWhite & Black CaribbeanAny other missed backgroundWhiteBritishIrishAny other white backgroundOther Ethnic GroupChineseAny other ethnic groupI do not want to disclose thisSexualityPlease select the option which best describes your sexuality. *LesbianGayBisexualHeterosexualReligion or belief Please indicate your religion or belief *AtheismBuddhismChristianityIslamJainismSikhismJudaismHinduismOtherI do not wish to disclose thisPreviousNextTo be used for those applicants that have been deemed appointable).To comply with the Equality Act 2010, please complete this questionnaire as fully as possible. Failure to do so could impede or delay your appointment. All information is confidential. Have you ever had or suffered from? Epilepsy/Blackouts *YesNoNervous Mental Disorders *YesNoMigraine/Headaches *YesNoSensory Impairment *YesNoSkin Allergies *YesNoBack pain/Previous Back Injury *YesNoHeart Condition *YesNoAsthmatic or respiratory ailments *YesNoRecurring Incidence of Illness *YesNoAre you registered disabled? *YesNoPlease detailPlease List Below any Periods spent Outside of the United Kingdom as a Resident (do not include holidays)1. Period Spent Outside the UK2. Period Spent Outside the UK3. Period Spent Outside the UKVaccinations or immunisationsPlease List below any vaccinations or immunisations1. Vaccinations or immunisationsDateImmunisationExpiry2. Vaccinations or immunisationsDateImmunisationExpiry3. Vaccinations or immunisationsDateImmunisationExpiryFinal declaration *I declare that the information given is correct to the best of my knowledge. In my view, I am fit physically and mentally to undertake this post. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references.PreviousSubmit