Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home

Any offer of employment may be made subject to a satisfactory medical report. (Your GP will not be contacted without your permission)

Note: Minimum age legislation dictates that Care workers in general must be 16 years old or older. Please inform your interviewer immediately if you do not meet these specifications.

Current or most recent Employer

Previous employer to the one above

Character reference

You will not be eligible for work in a Care setting if you are on the DBS Register(s)

I declare that to the best of my knowledge and belief the information given by me in this application is true, and I
understand that the above information forms the basis of my contract of employment. I understand that if any of
the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and
my employment may be terminated immediately.
I understand that I cannot be offered a post until a satisfactory response has been received with respect to my DBS
Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two
satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will
be subject to a satisfactory criminal record check from the DBS.
I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be
supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have
applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the
Nursing and Midwifery Council records and registers.
By my signature, I authorise the organisation to request a DBS Register check and a criminal records check from the
DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer
immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being
charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any
register of barred Care workers, or withdrawal of any registration required by my employment status.

The organisation is committed to promoting equal opportunities for all its employees and all prospective employees. To ensure that all applicants are dealt with equally, we wish to monitor your recruitment process and would ask for your help by completing the details below by placing a v in the appropriate box. This will allow the organisation to monitor its policies.

PLEASE NOTE

You do not have to complete this form. The information is given on a voluntary basis and the information provided will only be used for the monitoring purpose. Please do not enter any identifying marks on this form, so that your information remains confidential. This information will be stored on a computer.