Application Form

Please ensure that you complete the application form in full as we cannot accept CVs. Please complete with black ink and block capitals. This form will be kept confidential. Please note that no applicant will be unfairly discriminated against. This includes discrimination on account of age, cultural, religious, political beliefs, disability, ethnicity, gender, race, relationship status, sexual orientation, and / or Trade Union membership or stewardship.

If you have any special requirements to support you to complete this form (e.g. the need for large print or additional time), please contact Health Care Support Services on 01939 251342

Position Applied For:	Area:
Work Preference:	Full Time	Part Time	Bank	Hours Requested:
I understand this role may include shift work, unsociable hours, lone working, early mornings, evenings and alternate weekends. (Please circle your availability below)
Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
AM	PM	AM	PM	AM	PM	AM	PM	AM	PM	AM	PM	AM	PM
Evening	Evening	Evening	Evening	Evening	Evening	Evening
Weekend Arrangement

Date Completed:

Personal Details
First Name:	Address:
Surname:
Maiden Name:
Previous Name:
Marital Status:
Gender:	Postcode:
Date of Birth:	Nationality:
Telephone Number:	NI Number:
Mobile Number:	Email Address:
Are you a Driver?	Yes	No	Do You Have Your Own Transport?	Yes	No	N/A
How long have you held a licence?	Any Endorsements?	Yes	No	N/A
Are you a United Kingdom (UK), European Community (EC), European Economic Area (EEA) National?	Yes	No*
*If no, please detail your current immigration status and the relevant Visa currently held (including Visa number)

Are you related to any of our current members of staff or service users?	Yes	No
Equality Act 2010: Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a ‘substantial’ and ‘long-term adverse effect’ on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-under-equality-act-2010.
For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?	Yes	No	Prefer not to say
Education *(All qualifications will be subject to a satisfactory check).
School / College / University	Date From:	Date To:	Examinations, Qualifications*
Training Courses attended or completing (evidence of attending courses is required)
Subject	Location	Date	Details
Professional Memberships / Registrations
Name of Organisation	Registration Number	Renewal Date	Details

Employment History Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained. Use a separate attached sheet if required. Please sign the sheet(s).
Current / Most recent employer
Start Date:	End Date:	Salary:
Job Role:	Employer Name:
Reason for Leaving:	Contact Name:
Duties:	Address:
Postcode:
Telephone:
Email:
Employment History Continued
Start Date:	End Date:	Salary:
Job Role:	Employer Name:
Reason for Leaving:	Contact Name:
Duties:	Address:
Postcode:
Telephone:
Email:
Employment History Continued
Start Date:	End Date:	Salary:
Job Role:	Employer Name:
Reason for Leaving:	Contact Name:
Duties:	Address:
Postcode:
Telephone:
Email:
Employment History Continued
Start Date:	End Date:	Salary:
Job Role:	Employer Name:
Reason for Leaving:	Contact Name:
Duties:	Address:
Postcode:
Telephone:
Email:
Employment History Continued
Start Date:	End Date:	Salary:
Job Role:	Employer Name:
Reason for Leaving:	Contact Name:
Duties:	Address:
Postcode:
Telephone:
Email:
Employment History Continued
Start Date:	End Date:	Salary:
Job Role:	Employer Name:
Reason for Leaving:	Contact Name:
Duties:	Address:
Postcode:
Telephone:
Email:
Employment History Continued
End Date:	Salary:
Job Role:	Employer Name:
Reason for Leaving:	Contact Name:
Duties:	Address:
Postcode:
Telephone:
Email:

References: Do you give consent to Health Care Support Services gaining references? YES / NO Please provide names, addresses and telephone numbers for referees below whom we may approach for a reference. You must provide references from your two most recent employers. In line with CQC requirements, we require references covering your last five years’ employment. If you have not had more than one employer in the last five years, we require a further reference. Please provide two-character references if you are unable to obtain two professional references, e.g. in the case of an applicant who has been raising children for ten years. 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.
Referee One	Referee Two
Contact Name:
Business Name:
Address:
Postcode:
Telephone:
Email:
Capacity in which known
Referee Three	Referee Four
Contact Name:
Business Name:
Address:
Postcode:
Telephone:
Email:
Capacity in which known
Additional Referee	Additional Referee
Contact Name:
Business Name:
Address:
Postcode:
Telephone:
Email:
Capacity in which known
Safeguarding / Ex-Offenders Declaration: Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest confidence.
The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. The Organisation undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.
Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country?	Yes*	No
Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country?	Yes*	No

COVID-19 Vaccinations: Please note this section is required by law if the role you are applying for involves working within a care home.
The Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) Regulations 2021 make it mandatory for a person working in care to be fully vaccinated against COVID-19 from April 2022.
Are you fully vaccinated against COVID-19 or exempt from vaccination?	Yes	No
Are you able to evidence your vaccination or exemption status using the NHS COVID pass?	Yes	No
Privacy Statement
We will only collect data for specified explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to us holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you. When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles. We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant post. You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Registered Manager to discuss.

Supporting Statement Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe strengths and talents that set you apart from others as well as including skills gained from work, home, and other activities.

Values-Based Recruitment Screening Form

This should be completed before attending any interview. It will be discussed as part of the interview process.

If I was a service user, I would like:
I believe that the service user’s family and relatives would like the following:
I believe that I can support a service user because:
As a member of the team, I would feel valued when:

I believe that a good relationship between the service user and I depends upon:
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 relevant to my job role are:

Declaration
The information in this application form is true and complete. I agree that any deliberate omission, falsification, or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that Health Care Support Services Ltd can seek clarification regarding professional registration.
Print Full Name:
Signature:	Date: