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Join Our Caring Team at Nation Home Care: Make a Difference in People’s Lives!

Personal details:

Position applied for:

If other please specify:

Prefix

First Name

Middle Name

Last Name

Previous Surname(s) (if applicable

Date of birth

Email Address

Phone

Do you require a work permit to enable you to work in the UK?YesNo

Address for correspondence

City

ZIP / Postal Code

Country

Post reference no

National Insurance Number

Next of Kin details

Next of Kin Name

Next of Kin Phone

Next of Kin Email Address

Relationship to the Applicant

Next of Kin Street Address

Please answer the following question if the job/person profile for the job requires this.

Do you hold a current full driving license? *YesNoNot applicable for this role

If yes, is it a clean driving license?YesNoNot applicable for this role

If no, please give details:

Education History

1. Secondary School / College / University / Training Organization

Qualifications

Date from:

Date to:

2. Secondary School / College / University / Training Organization

Qualifications

Date from:

Date to:

2. Secondary School / College / University / Training Organization

Qualifications

Date from:

Date to:

Membership of Professional Bodies

Name:

Membership/StatusActiveNot Active

Renewal date

Memberhip number

Employment Experience

Please give details of your present or most recent employment/voluntary work first and work backwards. Include all periods of unemployment; travel etc, in the space provided so there are no gaps in the record.

1. Employer’s name

Nature of business

Employer’s address

Job titles and brief description of duties

Current salary or final salary (for last post only)

GBP

Reason for leaving

2. Employer’s name

Nature of business

Employer’s address

Job titles and brief description of duties

Reason for leaving

3. Employer’s name

Nature of business

Employer’s address

Job titles and brief description of duties

Reason for leaving

4. Employer’s name

Nature of business

Employer’s address

Job titles and brief description of duties

Reason for leaving

Gaps in your employment

Please provide information of any gaps in employment (Verification of employment gaps will be required if an offer of employment is made)

1. Employment gap date: from

Employment gap date: to

Reasons for the gap

2. Employment gap date: from

Employment gap date: to

Reasons for the gap

Address (Past 5+ Years)

1. Address date: from

Address date: to

Street Address

Country

2. Address date: from

Address date: to

Street Address

Country

3. Address date: from

Address date: to

Street Address

Country

References

Please ensure that you give a minimum of two references, which cover at least the last five years of your employment. The first of your references must be your present employer and your relevant line manager. If you are unemployed, this should be your last employer, or if this is your first job, your head-teacher or college tutor. Please note that Nation Home Care Ltd reserves the right to take up references in respect of any previous employment paid or unpaid, without further notification to you.

Full Name

Job title

Organization address (in full):

ZIP / Postal Code

Phone number

Email address

In what capacity do you know them?

Form Section

Previous employer/character's name:

Organization address (in full):

ZIP / Postal Code

Job title (if applcable):

Employer's phone number

Email address

In what capacity do you know them?

Please click or put x on the box that applies to you.

Can we contact your current employer prior to any conditional offer of employment?YesNo

Please note that it is Nation Home Care Ltd policy to obtain references prior to interview for any post in a residential establishment. For all posts, we will ask your referees for comments on your suitability for the post and for employment referees request details on attendance, sickness levels and salary.

Notice Period if appointed how soon you could join us:

Disability Nation Home Care Ltd has a policy of interviewing applicants who have a disability and who meet the essential short-listing criteria. To ensure that this happens, please complete the following:

a) The Disability Discrimination Act 1995 defines disability as' a physical or mental impairment which has a substantial and long-term adverse effect on the ability to carry out normal day-to-day activities. Do you consider yourself to have or have had a disability?YesNo

If yes, please give details

b) If the answer to the above is yes, are there any reasonable adjustments that need to be made, should you progress beyond this stage?YesNo

If yes, please give details

Relevant Experience

Please tell us how your experience, skills and qualifications meet the requirements of the person and job profiles. Please focus your response on the abilities and/or competencies required for the role giving evidence of your experience to date (maximum of 2 A4 sheets). The information you provide will be the basis for shortlisting and you may find it useful to refer to the guidance notes attached before completing this section.

Applicant Declaration

Declaration- To be completed by all applicants *I confirm that the information I have given is correct and complete and that any false statements or omissions may render me liable to dismissal without notice or in some instances, referral to the police.I understand and agree that data contained in the application form will be used and processed for recruitment purposes.I also understand and agree that should I become an employee; the information will also be used for employment related purposes.

I agree to Nation Home Care Ltd holding and processing this information.I Agree

Signature (Name Initials)

Date

Criminal Records/ Disqualification/ Other

Details of Declaration of Criminal Convictions (Please give details below):

Full Name

Full Address

ZIP / Postal Code

Phone

Signed:

Date

Rehabilitation of offenders Act (1974)

Because of the nature of the work for which you are applying, the provisions of Section 4(2) of the Rehabilitation of Offenders Act (1974) do not apply by virtue of the Rehabilitation of Offenders Act (1974) (exceptions) Order 1975. Applicants are therefore required to give information about convictions, which for other purposes are '‘pent’ under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the Order applies.

Have you at any time been convicted of an offence? (y/n)YesNo

If yes, please give details below: -

I declare that the information given above is, to the best of my knowledge, true, I am permitted to work in the UK. I have read, understood, and agree to the conditions of work for temporary nurses and carers, of which I have been given a copy. I understand that my registration is subject to the receipt of at least two satisfactory references and a satisfactory result after checking with the Department of Health and/or Police records.

I Declare

Your registration with Nation Home Care Ltd can be terminated at any time following unsatisfactory work reports

Signed:

Date

Criminal Records, Disqualification & Declaration

Section A- All applicants

Are you subject to any current outstanding disciplinary action or legal proceedings?YesNo

If yes please give details below

Section B-General posts - Criminal convictions

Have you ever been convicted of a criminal offence (‘unspent’ only)?YesNo

If yes, please give us details of all offences, penalties and dates on the page marked Criminal Record/Disqualification/Other in this application form.

Section C - Criminal record

Have you ever been convicted of a criminal offence or cautioned? Reprimanded or given a final warning by the police (‘spent’ or ‘unspent’)? If yes, please give details of all offences, penalties and dates on the page marked Criminal Record/Disqualification/Other in this application form.YesNo

If yes, please give details:

Regulatory body sanctions: Are you subject to any sanctions imposed by a regulatory body e.g., GSCC, NISCC, SCCC, CCW, GTC, RCN?YesNo

If yes, please give details:

Are you disqualified from working with children or vulnerable adults?YesNo

If yes, please give details below

Section D- Enhanced Disclosures only

Are you aware of any police enquiries undertaken following allegations made against you that may have a bearing on your suitability for the post?YesNo

If yes, please give details below

Health Declaration- To be completed by all applicants

Please answer the following questions by ticking the appropriate YES/NO box. If the answer to any questions is YES, then give details in the space provided or on the back of this form. It is your responsibility to inform us immediately if any of the following information changes. Have you ever had in your life, including childhood, any of the following?

Cardiac/Vascular IllnessYesNo

If YES, then please give details

Eye Disease/ Inquiry or Defect of Vision Not Corrected by LensesYesNo

If YES please give details

AsthmaYesNo

If YES, please give details

TuberculosisYesNo

If YES please give details:

DiabetesYesNo

If YES please give details:

Epilepsy, Frequent Fainting AttacksYesNo

If YES please give details:

Chicken PoxYesNo

If YES please give details:

Any Degree of hearing LossYesNo

If YES please give details:

HepatitisYesNo

If YES please give details:

Back pain, SciaticaYesNo

If YES please give details:

Do you have any deformities, which effect movements?YesNo

If YES please give details:

Are you receiving any medication from a doctor?YesNo

If YES please give details:

Have ever been treated for any other serious illness / operationYesNo

If YES please give details:

Are you a registered disabled person?YesNo

If YES please give details:

Mental IllnessYesNo

If YES please give details:

I believe that I am medically fit to carry out the duties of the position I have applied forYesNo

If YES please give details:

Are there any reasonable adjustments that an Employer should make to enable you to work?YesNo

If YES please give details:

General Practitioner’s

Name:

Full Address

Additional Information

I declare that all the foregoing statements are true and complete to the best of my knowledge and belief.I Declare

I hereby give Nation Home Care Ltd permission to contact my General Practitioner to obtain further information should it be required.YesNo

Signature

Specify Working Times

CheckboxFull timePart timeFlexible time

Type of work

Type of workCare HomesResidential HomesDay Care CentreDomesticKitchen AssistantDomiciliary CareHospitalCookLive in Care

I authorized Nation Home Care Ltd to pay my weekly/ Monthly earnings direct into the Bank/Building society Account whose details follow. I will notify Nation Home Care Ltd in writing of any change to these details

Bank Name

Bank Address

Account Number

Sort Code

Signature

Upload file

No file chosen

Date

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Personal details:

Next of Kin details

Please answer the following question if the job/person profile for the job requires this.

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