JOB APPLICATION

POSITION APPLIED FOR:

Job Reference:

Please complete this Application Form in block capitals in black or blue ink.

Should you require more space please continue on a separate sheet clearly marking the section to which it relates.

PERSONAL DETAILS

Title:

Forename(s):

Postcode:

E-mail address:

Surname:

Address:

Telephone:

Do you need a permit to work in the UK?

DRIVING RECORD

Do you have regular use of a car?

Current Driving Licence:

Details of any current endorsements :

Make / model / year:

Driving Licence valid from / To:

Do you have any driving-related prosecutions / fixed penalties / endorsements or similar currently pending?

If “YES” please provide brief details:

Have you ever been disqualified from driving?

If “YES” please provide brief details:

Have you ever had insurance refused?

If “YES” please provide brief details:

EDUCATION & PROFESSIONAL TRAINING (from year 11)

Secondary Education (secondary school):

Dates From - To:

Qualifications gained:

Higher Education (university / college / polytechnic):

Dates From - To:

Qualifications gained:

Further Education (Professional Training):

Dates From - To:

Qualifications gained:

Membership of Professional Organisations:

LANGUAGES

Languages (other than English):

PERSONAL DBS CERTIFICATES

If the position you are applying for (whether paid or voluntary) is listed in Schedule 1, Part II of the Rehabilitation of Offenders Act

(Exceptions) Order 1975, we are entitled to ask Exempted Questions as defined by Section 113(5) of the Police Act 1997 about you.

We are required to check a DBS Certificate in relation to any person who is a Care Manager or Care Worker. If your application is

successful and before your appointment is confirmed, you will be required to submit a personal current and valid DBS Certificate for

our inspection.

Having a criminal record will not necessarily bar you from working with us. This will depend upon the nature of the position and the

circumstances and background of your offences. We observe the “Code of Practice for Registered Persons and Other Recipients of

Disclosure Information” published through the Disclosure & Barring Service on behalf of the Home Office, and we will provide you

with a copy of it upon request.

EMPLOYMENT HISTORY

Please provide details of all employment, beginning with your present or most recent job first

Company Name:

Dates From - To:

Position(s) held:

Salary:

Reason for leaving:

Company Name:

Dates From - To:

Position(s) held:

Salary:

Reason for leaving:

Company Name:

Dates From - To:

Position(s) held:

Salary:

Reason for leaving:

VOLUNTARY & COMMUNITY WORK EXPERIENCE

Organisation:

Dates From - To:

Position(s) held:

Salary:

Duties:

JOB FLEXIBILITY

Prepared to work:

If PART-TIME please indicate preferred hours:

Details of any other work which you will continue to undertake if you are offered this Job Position:

Please provide details of any outstanding holidays to be taken:

AVAILABLE TO TAKE UP EMPLOYMENT FROM:

REFERENCES

Please provide details of 2 referees who we may approach with regards to this Job Application. These

referees must not be members of your family, and one must be your present or most recent employer:

Organisation:

Contact Name:

Telephone Number:

Address:

Occupation:

Organisation:

Contact Name:

Telephone Number:

Address:

Occupation:

May we contact your referees prior to making a job offer?

DECLARATION BY JOB APPLICANT

ANY PERSON, UPON SUBSEQUENT EMPLOYMENT, THAT IS FOUND TO HAVE KNOWINGLY SUPPLIED FALSE OR

MISLEADING INFORMATION, OR HAS DELIBERATELY WITHHELD RELEVANT INFORMATION, MAY BE SUBJECT TO

DISCIPLINARY PROCEEDINGS WHICH MAY RESULT IN DISMISSA

Please confirm:

I have read and understood the information supplied to me in relation to this Job Position, and the information requested in this Job Application Form. I confirm that all information supplied by me is true and correct to the best of my beliefs. I give the prospective employer the right to follow up all references and to make any other job-related enquiries as may be deemed necessary.

Date:

IS AN EQUAL OPPORTUNITIES EMPLOYER

The sole criterion for selection of applicants will be suitability for the Job Position, regardless of gender, background, culture, ethnic denomination,

religious affiliation, marital status or disability.

Data Protection Act 1998: Your signature on this document gives us the right, under the Data Protection Act 1998 to process the information you

have given, including data of a sensitive nature, relating to your application for employment. Any processing of the data by us will be in accordance

with our Policy and the processing principles set out in the Act. Application forms of unsuccessful candidates will be destroyed after 6 months in

accordance with our Record-keeping Policy.

Have questions?

Your local team of Client Care Managers are on call 24/7 to answer your questions and work with you to design a customized plan of care that is right for you.

JOB APPLICATION

PERSONAL DETAILS

DRIVING RECORD

EDUCATION & PROFESSIONAL TRAINING (from year 11)

LANGUAGES

PERSONAL DBS CERTIFICATES

EMPLOYMENT HISTORY

VOLUNTARY & COMMUNITY WORK EXPERIENCE

JOB FLEXIBILITY

REFERENCES

DECLARATION BY JOB APPLICANT

Have questions?

SERVICES

COMPANY

HEAD OFFICE

DERBYSHIRE BRANCH