PERSONAL INFORMATIONPosition applied for Approx. no. of hours wantedType of ContractFull-TimePart-TimeAvailabilityDaysNightsMorningsAfternoonsEveningsWeekends OnlySurname *Name(s) *Previous surnames (Supply documentary evidence e.g. marriage certificate, deed of name change etc)Email Address *Current Address *Post Code: *Moved to this address on (date):Previous address Note: For Criminal Record check purposes, addresses covering the five years up to the application date must be supplied. If necessary, use another sheet of paper.Post Code:Moved to this address on (date):Telephone Number (home) *Telephone Number (work)Own TransportYesNoClean driving licenceYesNoSelectHow long has your licence been held?1 Year2-Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 YearsMore than 10 YearsEndorsementsEDUCATIONSchool/College/UniversityExaminations Passed/Qualifications gainedTRAINING HISTORY/PROFESSIONAL STATUSDate of Graduation/QualificationLocation/Details NotesSHORT COURSES ATTENDEDSubjectsLocationEMPLOYMENT HISTORYCurrent/most recent first. Information must cover the whole of your working life to date. State the reasons for any breaks in employmentName and address of your most recent/last employerDate employedNature of businessPosition held and reason for leavingSalary / RateName and address of your most recent/last employerDate employedNature of businessPosition held and reason for leavingSalary / RateName and address of your most recent/last employerDate employedNature of businessPosition held and reason for leavingSalary / RateOther roles (use additional sheet): Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own homeASSISTANCE WITH INTERVIEW AND ASSESSMENTDo you require us to make any special arrangements in order for you to participate in the recruitment process? For example, large print forms? Or additional time to complete forms? YesNoIf yes, please give detailsAny offer of employment may be made subject to a satisfactory medical report. (Your GP will not be contacted without your permission)GP’s nameTelephone noAddressNEXT OF KINFull nameRelationshipTelephone noAddressIDENTITY DETAILSNursing and Midwifery Council PIN number. (Nurses only)National Insurance NumberCAPACITY TO WORK IN THE UKAre there any restrictions to your residence in the UK which might affect your right to take up employment in the UK? YesNoIf yes, please provide detailsIf you are successful in the application, would you require a work permit prior to taking up employment? YesNoNote: 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. REFEREESYou must provide references from your two most recent employers. Please provide an additional character referee. All will be contacted, therefore please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with usCurrent or most recent EmployerNameTelephone noJob TitleAddressPrevious employer to the one aboveNameTelephone noJob TitleAddressCharacter referenceNameTelephone noRelationship to youAddressCRIMINAL RECORDWorkers of The Agency are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.You will not be eligible for work in a Care setting if you are on the DBS Register(s)Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.SIGNATURE and DECLARATION – IMPORTANT – READ BEFORE SIGNINGI declare that to the best of my knowledge and belief the information given by me in this application is true, and Iunderstand that the above information forms the basis of my contract of employment. I understand that if any ofthe information supplied by me is found to be falsely declared, my contract may have been fundamentally breached andmy 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 DBSRegister status, and that should I subsequently be offered a post, that offer will be subject to receipt of twosatisfactory references, one of which must be from my previous employer, and that confirmation of the employment willbe 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 besupervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I haveapplied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of theNursing 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 theDBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employerimmediately if my DBS Register status or criminal status changes at any time during my employment, such as by beingcharged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to anyregister of barred Care workers, or withdrawal of any registration required by my employment status.SignedDateEQUAL OPPORTUNITIES MONITORING FORM INTERVIEWER – DETACH THIS FORM FROM THE PACK AND HAND IT TO THE CANDIDATE, TOGETHER WITH A STAMPED ADDRESSED ENVELOPE. NO MARKS TO IDENTIFY THE CANDIDATE MAY BE MADE – THE REPLY IS ANONYMOUS AND CONFIDENTIAL.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.GenderMaleFemaleRegistered Disabled? YesNoChildrenYesNoMarital StatusSingleMarriedDivorcedAgePlease indicate your ethnic background:AfricanAsianAfro-CaribbeanUK EuropeanEuropeanOtherOther(Please specify) Send Message