3-DIMENSIONS CARE LTD.

Application Form

*All information will be treated as confidential

The information on this application will be used to evaluate your

suitability for employment with 3-Dimensions Care Ltd.

You will be informed in writing if you are successful in achieving entry into the first stage of the interview process. We will also inform you if you have been unsuccessful. Please also complete this form in block capitals, in black ink, and return it by email to or by post to The HR Department, 3 Dimensions Care Ltd, Chardleigh House, Chardleigh Green, Wadeford, Chard, Somerset TA20 3AJ

PLEASE FILL IN ALL THE REQUIRED FIELDS. ANY APPLICATION FORM NOT FILLED IN CORRECTLY WILL NOT BE PROCESSED.

SECTION 1

Position applied for: / Date:
First Name(s): / Mr/Mrs/Miss/Ms
Last Name(s) / National Insurance No:
Maiden Name (if applicable) / Date of Birth:
Address for correspondence:
Daytime Tel. No:
Post Code: / Evening Tel No:
Email: / Mobile No:
2.QUALIFICATIONS AND TRAINING / For official use only
Date (From/To) / Secondary school/ college/
university/ Training organization / Qualifications / Subject / Grade obtained / Verified at interview
QUALIFICATIONS AND TRAINING CONT’D.
Date (From/ To) /
Secondary school/ college
University / training /
Organization /
Qualifications
/
Subject
/ Grade obtained / Verified at interview
3. Employment Experience

Note:Please give details of your present or most recent employment/voluntary work first and work backwards. Include a note of all periods of unemployment; travel etc. in the space provided so there are no gaps in the record. (If you have additional previous employment, please give details on a separate sheet using the same format).

**Applicant must give the month & year of when they started and finished employment.

**Date from/to
(month year) / Employer’s name and address and nature
of business / Job titles and brief
Description of duties / Current salary or final
Salary (for last post only)
And reason for leaving

Employment Experience Cont’d.

Date: from/ to
(month/ year) / Employer’s name and address and
Nature of business / Job titles and brief
Description of duties / Current salary or final salary
(for last post only)
and reason for leaving

4. Gaps in your Employment –Please provide information of any gaps in employment

From (month/year) / To (month/year) /
Reason for Gap in Employment

For office use only

Documentary Evidence Provided for Gaps in Employment / Date / Signed

5. Relevant Experience

Please tell us how your experience, skills and qualifications meet the requirements of the person and job profiles. Please focus your response on the abilities and or competencies required for the role giving evidence of your experience to date. The information you provide will be the basis for short-listing.

6. Additional Information

Please use this section to give additional information about yourself e.g. hobbies, interests, background history.

7. References(Please refer to guidance notes below before completing)

Please ensure that you give a minimum of four references, one of which is your currentemployer and at least two from your previous employers,plus a personal referee. PLEASE ALSO INCLUDE the contact details for any employment in which you have worked with children, including voluntary, using a separate sheet if necessary.3-Dimensions Care Ltd reserve the right to take up references in respect of any previous employment paid or unpaid without further notification.

Please note, we cannot accept any references from family members.

Current employer Previous employer (1)

Mr/Mrs/Miss/Ms: / Mr/Mrs/Miss/Ms:
Referee’s Job title: / Referee’s Job Title:
Company Name & address (in full) / CompanyName & address (in full)
Post Code: / Post Code:
Tel. No: / Tel. No:
Fax No: / Fax No:
Email: / Email:
In what capacity do you know them? / In what capacity do you know them?

Previous employer (2) Character reference/Personal referee

Mr/Mrs/Miss/Ms: / Mr/Mrs/Miss/Ms:
Referee’s Job title: / Home or Company Address:
Company Name & address (in full)
Post Code: / Post Code:
Tel. No: / Tel. No:
Fax No: / Fax No:
Email: / Email:
In what capacity do you know them? / In what capacity do you know them?

Can we contact your current employer prior to any conditional offer of employment? Yes No*

8. Current Driving Licence

YesNo

Please give details of any endorsements.

9. Professional Complaints

Has anybody ever made a professional complaint against you? Yes No

Or have you ever been involved in any disciplinary action?

(If yes, please give details below)

10. Disclosure and Barring Service Check

National Care Standards Act 2000 and The Children’s Act 1989 and the Care Quality Commission require a DBS check to be carried out for all employees in a position held with access to adults, children and young people.

Should you be successful in your application we are required to complete an application form for a DBS check.

It is 3-Dimensions Care Ltd. policy to carry out enhanced Disclosure and Barring Service checks.

Would you agree to this check?YesNo

(Information received would be kept in the strictest confidence)

Criminal convictions

Please list any criminal convictions giving dates and details. (If none, please state none).

11. Other Addresses:

You must provide all other addresses where you have lived in the last 5 years. There must be no gaps in dates,

However, overlapping dates are acceptable.

Address 1: Present Address
Please fill in dates:
Post Code: / From: / To:
Address 2:
Post Code: / From: / To:
Address 3:
Post Code: / From: / To:
Address 4:
Post Code: / From: / To:
Address 5:
Post Code: / From: / To:

I confirm that the information I have given is correct and complete and that misleading or untruthful statements will

result in my dismissal if they become known after my appointment.

Signed: …………………………………………………… Date: …………………………………

Equal Opportunities monitoring form - CONFIDENTIAL

To ensure no-one experiences unfair discrimination, please complete the following questions and return with your application form.

3-Dimensions Care Ltd, is committed to achieving equality of opportunity and continually monitors the effectiveness of its policy. To do this we ask applicants to supply information about their ethnic origin, gender, age, marital status and whether they have a disability. The information is confidential and is not seen by the selection panel. It will also only be used to monitor our recruitment and selection process. Using this information we can work to ensure that no-one experiences unfair discrimination.

Please tick the appropriate box in each of the following sections.

Age 20-25 25-30 31-45 46-60 Over 60

Marital status Single Married Separated Widowed

Divorced Living with partner

Gender Male Female

Do you have a disability? Yes No

Would the provision of any aids or modifications assist you in carrying out the duties of the post?

Yes No

If yes, please give details.

Equal opportunities monitoring form –Cont’d.

Nationality

How would you describe your ethnic origin? (As defined in 2001 census)

White British Irish Scottish Welsh Any other White background

Mixed White & Asian White & Black African White & Black Caribbean

Any other mixed background

Asian, Asian British, Asian English, Asian Scottish, Asian Welsh

Indian Pakistani Bangladeshi Any other Asian background

Black, Black British, Black English, Black Scottish, Black Welsh

Caribbean African Any other Asian background

Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh or other ethnic group

Chinese Any other ethnic background

Where did you see the advertisement for this post? Please circle the appropriate answer.

Websites: Careerbuilder.co.uk / job.westerngazette.co.uk / Other (please state): ……………………………………….

Newspapers: Somerset Gazette / Western Gazette / Bridport News / View from East Devon / Other – (please state)

……………………………………………………………………………………………………………………………………...

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