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Application Form
Your Name prefix, Mr or Mrs?
Data Protection Statement: The personal information (data) collected on this form, and on the attachments, (which includes the collection of sensitive personal data) are collected for the purposes of recruitment, personnel administration (for new employees) and monitoring. Unless you direct otherwise (for example in a situation where you would like this Application kept on file for future vacancies) the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6 months. It is the policy of the Agency to protect, and keep secure, all personal data collected. All personal data is processed for the purposes of recruitment, and, in the case of successful Applicants, for the satisfactory administration of their employment, and for no other purpose.
Equality of Opportunity Statement The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.
1. Personal Details
Title
Mr
Mrs
Miss
Ms
Other
Surname
Maiden name
Previous surnames (if any)
Forename (in full)
E-mail
Telephone (home)
Telephone (work)
Telephone (mobile)
Full Address
Postcode
Date of Birth (dd/mm/year)
May we contact you at work?
Please select
Yes
No
National Insurance Number
Name of Next of Kin to be notified in case of emergency:
Next of Kin address
Next of kin postcode
Next of kin telephone (Home)
Next of kin telephone (work)
Next of kin telephone (mobile)
Next of kin relationship to you
2. General information
Are you eligible to work in the UK?
Yes
No
Do you hold a valid and current driving license?
Yes
No
If yes, what type?
Do you have any endorsements?
Yes
No
If yes, please give details
Do you own a car?
Yes
No
Are you able to communicate effectively in English (spoken and written)?
Yes
No
Please list any other languages that you are able to speak
Do you have any care experience?
Yes
No
Please give brief details of any past care experience
3. Rehabilitation of Offenders Act As a general rule, no-one need answer questions about spent convictions. However this general rule does not apply to specified professions, employments and occupations. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to: a) any employment or other work which is concerned with the provision of health services and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to persons in receipt of such services in the course of his normal duties, or b) any employment or other work which is concerned with the provision of care services to vulnerable adults and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to vulnerable adults in receipt of such services in the course of his normal duties One or both of the above apply to work with the Agency, and covers all occupations. You are therefore requested to provide details of all convictions, including those which would otherwise be considered as “spent”. All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected.
Are you subject to any current disciplinary action
Yes
No
Have you ever been convicted of a criminal offence, cautioned, sentenced, reprimanded or given a final written warning by the police?
Yes
No
Criminal Records – Disclosure Certificate
Disclosure Scotland have issued a Code of Practice regarding Disclosure Information, a copy of which is available upon request. A PVG Certificate (standard or enhanced) will be requested from Disclosure Scotland which will detail all convictions, including those which would otherwise be “spent”, as well as details of cautions, reprimands or final warnings. You will be advised of the type of certificate being requested, and asked to give your approval to this application. The PVG Certificate will only be requested in the event that you are successful in your application for employment.
Asylum and Immigration Act 1996
Under Section 8 of the Asylum and Immigration Act 1996 it is a criminal offence to employ a person aged 16 or over who is subject to immigration control unless: That person has current and valid permission to be in the United Kingdom and that permission does not prevent him or her from taking the job in question; or The person comes into a category specified by the Home Secretary where such employment is allowed Any employment offered will be subject to the successful applicant producing appropriate evidence that the Asylum and Immigration Act is not being contravened.
Are you eligible to work in the UK?
Yes
No
Personal Declaration
I declare that to the best of my knowledge the above information, and that submitted in any accompanying documents, is correct, and I give permission for any enquiries that need to be made to confirm such matters as qualifications. experience and dates of employment, and for the release by other people or organisations of such information as may be necessary for that purpose. I give permission for the processing of the personal data contained in this form for employment purposes I understand that any false or misleading information could result in my dismissal.
Enter full name
Date
4. Confidentiality declaration
Registration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about your clients. On no account must information relating to identifiable clients be divulged to anyone other than the manager of the agency. You should not disclose ANY information to your family, friends or neighbours. If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER. Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register.
I have read and I understand the above and I agree to abide by the contents therein
Agreed
5. Preference regarding work
Are you looking for full-time or part-time hours?
Part time (30 hours or fewer)
Full time (over 30 hours)
Type of work
NHS
Private hospitals
Nursing home
Industry
Clients in their own home
Other, please specify
Other type options
Live in
Days
Nights
Visits
Do you have any other work commitments?
Yes
No
Which areas of work do you wish to exclude?
When will you be available to start work?
6. Additional Information
Give details of any additional information which you would like to include in support of your application. Such information, for example, may include skills and/or achievements which you think may be of interest, and/or a summary of why you believe that you have the qualities we are looking for. Please provide details of any relatives employed by the Agency and there relationship to you.
Additional information
7. References
References are normally taken up for candidates selected for interview. Give details of the names/addresses of two work-related Referees. One of the Referees should be your current employer, or if presently unemployed or self-employed, your last employer.
Name, Address and Postcode
Telephone number
Position
Relationship to you
May we contact your reference now?
Please select
Yes
No
8. Equal Opportunities Monitoring Form
A1 Care operates a policy of Equal Opportunities: therefore, we need to be able to check that decision are not influences by unfair or unlawful discrimination. To help use to do this we would be grateful if you could complete this short questionnaire. Your answers will be treated with the utmost confidence and will be used only for statistical purposes.
What is your ethnic group?
White Irish
White British
White and black Caribbean
White and black African
White and Asian
Indian/British Indian
Pakistani/British Pakistani
Bangladeshi/British Banglades
Caribbean/British Caribbean
African/British African
Chinese
Other Ethnicity
Gender
Male
Female
Applicants with disabilities will be invited for interview if the essential job criteria are met. Do you consider yourself to be a person with a disability as described by the disability discrimination act 1995? i.e do you consider yourself to be someone who has a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day to day activities?
Yes
No
9. Formal Education and Qualifications
Please list the name of the establishment attended, enrolment date, completion date and any qualifications gained
10. Employment History
Please list the name and address of employers, the employment start and end dates, your positions and responsibilities and reasons for leaving if applicable
Submit
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I Agree