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STANDARDS
 
In order to guide the interview process, we would like you to indicate your personal philosophy of Care by completing the following statement:

I believe that the purpose of Care from a Care service is:	 
 	
If I were Service User in The Agency I would like:	  
 	
I believe that the Service User’s family and relatives would like from The Agency:	  
 	
I believe that I can support a Service User in The Agency because: 	  
 	
As a member of The Agency Care team I feel valued when:	 

I believe that a good relationship between me and the Service User depends on:	  
 	
I believe that I learn best when:	  
 	
I believe that a good working team is made by: 	 

I believe that my role in relation to the Service User is:	  
 	
My other beliefs and values of relevance to my job are:	  

APPLICATION FORM
 
The recruitment process within this organisation has a minimum of three stages.
The completion of this application form is part of stage one. This application will be reviewed and a decision made as to whether to proceed to stage two, the interview, based on this information, stage 3  on the date of the interview you will be asked to complete a basis literacy and numeracy test, you must get a 80% pass mark. 

PLEASE COMPLETE FULLY AND IN CAPITALS.

Position applied for:	 Support Worker	
Approx. no. of hours wanted	 	
Full-time / part-time
(please circle which you want to work)	Days/ Nights/Mornings/Afternoons/Evenings/ Weekends only
(please circle which you are able to work)	
Surname:	First name(s):	
Previous surnames (Supply documentary evidence e.g. marriage certificate, deed of name change etc):	 	
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 - will be used with discretion):	
Own Transport (Yes/No):
How long has your licence been held?	Clean current driving licence:
Endorsements:	
Details:	 	

EDUCATION
School/College/University	Examinations Passed/Qualifications gained	

 

 

 	(Please supply copies of certificates)

 

TRAINING HISTORY/PROFESSIONAL STATUS
Date of Graduation/Qualification	Location/Details	Notes	

 

 

 

 

 	(Please supply copies of certificates/membership details)

 

 	 	
SHORT COURSES ATTENDED
Subjects	Location	

 

 

 	 

 	

EMPLOYMENT HISTORY
 
Current/most recent first. Information must cover the whole of your working life to date. State the reasons for any breaks in employment. Use a separate attached sheet if required; please sign that sheet(s).
Name and address of your most recent/last employer:	 	
Date employed:	 	
Nature of business:	 	
Position held and reason for leaving:	 	
Salary / Rate:	 	
Name and address of Employer prior to the employer listed above:	 	
Date employed:	 	
Nature of business:	 	
Position held and reason for leaving:	 	
Salary / Rate:	 	
Name and address of Employer prior to the employer listed above:	 	
Date employed:	 	
Nature of business:	 	
Position held and reason for leaving:	 	
Salary / Rate:	 	
Other roles (use additional sheet):	 	

 	 	

 	 	
 	 	
Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home. Please use separate sheet if insufficient space is available.

ASSISTANCE WITH INTERVIEW AND ASSESSMENT

Do 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?
Yes / No	
If yes, please give details:
 	
Any offer of employment may be made subject to a satisfactory medical report. 	
GP’s name:	 	
Tel no:	 	
Address:	 	
(Your GP will not be contacted without your permission)	

NEXT OF KIN
Full name:	 	
Relationship:	 	
Tel no:	 	
Address:
 	
IDENTITY DETAILS
Nursing and Midwifery Council PIN number:	(Nurses only)
 	
National Insurance Number:

	(all applicants)

CAPACITY TO WORK IN THE UK
Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK? 	Yes / No (delete as appropriate)	
If yes, please provide details.

 

 
 	
If you are successful in the application, would you require a work permit prior to taking up employment? 	Yes / No (delete as appropriate)	
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.

REFEREES
 You 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 us.
Current or most recent Employer
Name: 	 	
Address:		
Post code:	 	
Tel No: 	 	
Job title:	 	
Previous employer to the one above
Name: 	 	
Address:	 	
Post code:	 	
Tel No: 	 	
Job title:	 	
Character reference
Name: 	 	
Address:	 	
Post code:	 	
Tel No: 	 	
Relationship to you:	 	

CRIMINAL RECORD
 
Workers 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 SIGNING	
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.

 Signed: _______________________________________________ Date:_____________________

EMPLOYMENT CONTINUITY CHECK
 
It is essential to check the continuity of employment, as stated in the application form, and to note and investigate any gaps in employment. Failure to carry through such checks has been identified as a significant factor in several recent abuse cases.
Use the “timeline” below to place in order all stated instances of employment and other activities (such as training), and identify any gaps for discussion during the interview. Assess and record the results of the enquiries, which must be followed through if interview answers are unsatisfactory.
The period considered must be the whole working life of the applicant, to date.

Example: