Application Form
Post Applied For:
Title: First Name(s):
Surname: Any previous names
(If applicable):
Telephone Mobile Telephone
Number: Number:
Address:
Postcode:
Email Address:
National Insurance Number:
Minimum hours available to work:
Maximum hours available to work:
Do you hold a current full driving Yes / No
licence?
Do you have a clean driving licence? Yes / No
Do you have access to a car during work Yes / No
hours?
Do you have business insurance? Yes / No
Are you entitled to work in the UK? Yes / No
Are you registered with the DBS online Yes / No
update service?
Education and Qualifications
Secondary School:
Date from: Date to:
Subjects: Grade: Subjects: Grade:
College:
Date from: Date to:
Subjects: Qualifications Gained: Grade:
University/Further
Education:
Date from: Date to:
Subject: Qualifications Gained: Grade:
Vocational Training Courses
Do you have any of the following NVQ or Level 2 / Level 3 / Level 4 / Level 5
diploma equivalent in health and social
care?
Do you have English and Maths Yes / No
Qualifications level 2 and/or above?
Have you completed the Care Certificate? Yes / No
Are you a member of any relevant Yes / No
professional associations?
If yes please provide details.
Please list any other vocational training courses you have completed.
Course: Provider: Date Completed:
Employment History
You are required to provide a full employment history
Current
Employer:
Address:
Reason for
Leaving:
Job Title:
Start date:
Brief Description of Duties Undertaken:
Notice Required in
Current Job:
Previous Employment - All gaps in employment must be accounted for. Please continue
on an extra sheet if necessary.
Name & Address of Date Job Title Main Responsibilities Reason for
Previous From / Leaving
Employer(s) To
Have you ever been dismissed or requested to resign Yes / No
from any previous employment?
If yes please provide details below.
Name & Address of Date Type of Employment Reason for
Previous Dismissal/Request
Employer(s) to Resign
Have you ever been the subject of formal disciplinary Yes / No
action in any previous employment?
If yes please provide details below:
Name & Address of Date Type of Employment Details of Formal
Previous Disciplinary Action
Employer(s)
Statement in Support of Application
Please use this section to provide information to support your application.
Refer to the job description and person specification to support your application and
provide specific examples where possible.
What motivates you to work in Social Care?
Why do you want to work for our organisation?
What skills and values would you bring to the role?
How would you promote our clients’ independence?
Give an example of how you have promoted dignity and respect.
Give an example of how you have demonstrated compassion.
Give an example of something you have achieved as part of a team.
Please use this space to provide any other information in relation to your application.
This could include voluntary work, life experience or transferable skills.
References
Please provide three references, one of which must be your current/last employer.
If you have previously worked in health and social care please provide reference details
for these employers.
When stating an employer for a reference please provide their business address, not
their private address.
Relatives and friends may not be used as a referee.
References will only be contacted after an offer of employment has been made.
Reference 1 (Current/Most Recent Employer)
Name: Relationship/
Job Role:
Address:
Email: Telephone:
Date from: Date to:
Reference 2
Name: Relationship/
Job Role:
Address:
Email: Telephone:
Date from: Date to:
Reference 3
Name: Relationship/
Job Role:
Address:
Email: Telephone:
Date from: Date to:
Disclosure of Criminal Background
Due to the nature of the service we provide, all offers of employment will be subject to
a satisfactory enhanced disclosure via the Disclosure and Barring Service (DBS).
The post for which you are applying does not entitle you to rely on the Provisions of the
Rehabilitation of Offenders Act 1974. All previous convictions must be disclosed.
If you disclose that you have a criminal conviction, and your application is successful,
this will be discussed in confidence at interview.
If you do not disclose any convictions you have then this may result in your application
being rejected, or any conditional job offer you have received being withdrawn. If you
are appointed, this non-disclosure may later lead to your dismissal.
Any applicants who disclose convictions will be treated fairly, and will be provided with
the opportunity to evidence their suitability for the post for which they are applying.
Any information provided will be kept confidential, and will only be used in relation to
your application. Only convictions relevant to the post for which you are applying will
be taken into account.
Have you ever been convicted of a criminal offence? Yes / No
If yes, you will be asked to provide details if selected for
interview.
Conflict of Interest/Relationships
Do you have a pre-existing relationship Yes / No
with anyone associated with the
organisation or any of the people we
support?
This may be a family relationship,
friendship, or other.
If yes, please provide the information
requested below:
Name: Relationship With You: Relationship With The
Organisation
e.g. staff member, person
we support
Are you aware of any other conflicts of
interest you may have with the
organisation?
If yes please provide detailed information.
Where did you hear about this position?
Declaration
I declare that to the best of my knowledge and belief all the information I have
provided in this application form is true and correct.
I understand that providing incorrect information or deliberately concealing any
relevant information, may result in disqualification from the selection process, or any
conditional job offer you receive being withdrawn. If you are appointed, this may later
lead to your dismissal.
Signature: Date:
Please return your completed application to us by post or email.
