Position interested:

Support Worker daysSupport Worker NightsSupport Worker WeekendsSupport Worker Any

Personal details:

Are you permitted to work in the United Kingdom?
—Please choose an option—YesNo

Title:
—Please choose an option—Mr.MrsMissMsMxSirDrLadyLord

First Name: *

Last Name: *

Address Line 1/Unit: *

City:

County:

Postal Code: *

Date of Birth: *

Email Address: *

Mobile Phone: *

Home Phone:

Your Email: *

Your National Insurance Number: *

Do you have a full Driving Licence that allows you to drive in the UK?
—Please choose an option—YesNo

Do you have access to a car that you can use for work?
—Please choose an option—YesNo

Have you ever been banned from driving, or do you have any current endorsements on your licence?
—Please choose an option—YesNo

References:

Please provide us with two references, one of whom should be your present or most recent employer

Reference 1

Name:*

Job Title:*

Organisation:*

Address Line 1/Unit: *

City:

County:

Postal Code:*

Tel Number:*

Dates from / to:*

Capacity in which they know you (e.g. Line Manager):*

May we contact this reference prior to interview?
—Please choose an option—YesNo

Reference 2

Name:*

Job Title:*

Organisation:*

Address Line 1/Unit: *

City:

County:

Postal Code:*

Tel Number:*

Dates from / to:*

Capacity in which they know you (e.g. Line Manager):*

May we contact this reference prior to interview?
—Please choose an option—YesNo

Education / Qualifications / Training

Please give information about qualifications gained relating to the role you are applying for:*

Date: *

Five year address history if less than five years at current address:

Address 1

Address Line 1/Unit:

City:

County:

Postal Code:

Address 2

Address Line 1/Unit:

City:

County:

Postal Code:

Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986 provides that people in employment which is concerned with the provision of care or who carry out their duties wholly or partly on the premises where such provision takes place are obliged to disclose any convictions which would otherwise be spent. The Care Home Regulations provide that people in employment which is concerned with the provision of care or who carry out their duties wholly or partly on the premises where such provision takes place are obliged to disclose any criminal convictions, conditional discharges, bindovers or cautions that they have been subject to at any time in the past.

Have you ever been convicted of a criminal offence or received a Police Conditional discharge, bind-over, caution, warning or reprimand?
—Please choose an option—YesNo

Have you ever been issued with a Penalty Notice for Disorder?
—Please choose an option—YesNo

If so, what was the offence?

Making a false statement or any attempt to conceal information regarding this declaration will lead to the rejection of your application for employment with this company. Any details provided will be treated in the strictest confidence and will not automatically exclude anyone from being considered for any vacancy.

Declaration

I have completed an Application for a Criminal Disclosure and can further state that to the best of my knowledge and belief, there will not be any positive disclosure made that will preclude me from working with vulnerable adults or children.

Full Name:*

Signature:*

Date:*

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