Page 1 of 4 / RAYSON HOMES LTD FORM No 01 – 1 – 05
JOB APPLICATION
Version 1.0 / Rayson Homes Ltd Updated 2012 / © R.N.H.A. 2010
POSITION APPLIED FOR: / Job Reference:
Please complete this Application Form in block capitals in black or blue ink
A: PERSONAL DETAILS
Title (Mr/Mrs/Miss/Ms/other): ______
Surname: ______Forename(s): ______
Address: ______
Address: ______Postcode: ______
Telephone Contact Details Home: ______
Business: ______Mobile: ______
Date of Birth: ______Place of Birth: ______Nationality: ______
B: HEALTH
Number of DAYS absent from work in the last 2 years ______Number of periods of absence ______
Comments______
______
Are you prepared to undergo a medical examination? YES / NO
C: TRANSPORT / DRIVING
How would you propose to get to work CAR / PUBLIC TRANSPORT / TAXI / WALK / OTHER
Are you a car owner? YES / NO Current Driving Licence: PROVISIONAL / FULL / PSV / NONE
Driving Licence valid from: ______to: ______
Do you have any Endorsements on your Licence? YES / NO
Details of current endorsements :
______
Have you ever been disqualified from driving, or had insurance refused? YES / NO
If "YES" please provide brief details:
______
Page 2 of 4 / RAYSON HOMES LTD FORM No 01 – 1 – 05
JOB APPLICATION
Version 1.0 / Rayson Homes Ltd Updated 2012 / © R.N.H.A. 2010
D: EDUCATION & PROFESSIONAL TRAINING (from year 11)
Education Centre (school, college etc) / DATES / Qualifications gained
From / to
1. Secondary Education (secondary school)
2. Higher Education (university / college / polytechnic)
3. Further Education (Professional Training)
4. In-house training certificates (e.g. first aid, moving & handling, infection control, food safety etc)
5. Membership of Professional Organisation / Trade Union

E: LEISURE ACTIVITIES

Please provide brief details of your hobbies, sport and other leisure pastimes in which you participate:
Languages (other than English) : ______SPOKEN / FLUENT / WRITTEN / READ
: ______SPOKEN / FLUENT / WRITTEN / READ

F: CRIMINAL RECORD 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. From July 2002 we are required by The Care Home Regulations 2001 to acquire a Criminal Record Certificate in relation to any person who is a Care Manager or Care Worker. This means that if your application is successful we will obtain from the Criminal Records Bureau a Criminal Record Certificate relating to you before your appointment is confirmed.
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 by the Criminal Records Bureau on behalf of the Home Office, and we will provide you with a copy of it upon request.
Signature: ______Date: ______
Page 3 of 4 / RAYSON HOMES LTD FORM No 01 – 1 – 05
JOB APPLICATION
Version 1.0 / Rayson Homes Ltd Updated 2012 / © R.N.H.A. 2010

G: EMPLOYMENT HISTORY

Have you had any ‘gaps’ in your employment history Yes / No (Please provide dates and reason/s for any gaps below)

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

(Continue on a separate sheet if required)

DATES / Employer / Salary / Position(s)
Held /

Reason for leaving

from / to

H: VOLUNTARY & COMMUNITY WORK EXPERIENCE

DATES / Organisation / Position(s) held / Duties
from / to

I: JOB FLEXIBILITY

Prepared to work: FULL-TIME / PART-TIME Shifts: DAYS / NIGHTS / BOTH
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 planned holiday dates: ______
I AM AVAILABLE TO TAKE UP EMPLOYMENT FROM: ___/___/____

J: WHY YOU WOULD LIKE THE JOB

(In no more than 100 words please make reference to relevant skills, your attitude and disposition etc )

Page 4 of 4 / RAYSON HOMES LTD FORM No 01 – 1 – 05
JOB APPLICATION
Version 1.0 / Rayson Homes Ltd Updated 2012 / © R.N.H.A. 2010

J: 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 the manager at your present or most recent employer:
1. Name: ______
Address: ______
______
Telephone Number: ______
Occupation: ______
2. Name: ______
Address: ______
______
Telephone Number: ______
Occupation: ______

K: 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, WILL BE SUMMARILY DISMISSED
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.

Signature: ______Date: ______

RAYSON HOMES LTD 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.
Page 1 of 1 / RAYSON HOMES LTD FORM No 01 – 1 – 11
EQUAL OPPORTUNITIES & DIVERSITY MONITORING
JOB APPLICANTS
Version 1.0 / Rayson Homes Ltd Updated 2012 / © R.N.H.A. 2010
Rayson Homes Ltd is committed to being an equal opportunities employer and we welcome applications from all sections of the community. We will ensure that all candidates for employment are treated fairly, and in order to monitor our responsibilities and to measure our progress towards widening diversity among our workforce, we would be grateful if you would answer the simple questions in the boxes below. The information you provide will remain anonymous and is for statistical monitoring purposes only. This 2-page form will be separated from your application upon receipt and is not used as part of the applicant selection process.

Name ______Application Date ______Post Title: ______

(Please tick the appropriate box’s below)

A: BASIC DETAILS
Your age range: / 16 - 20 / Your marital status: / Married / Nationality:
21 - 25 / Married / separated / Your gender: / Male
26 - 49 / Divorced / Female
50 - 60 / Single / Transgender
60+ / Widowed
B: ETHNICITY (2001 Census classification)
Please tick the box alongside the category that you feel best describes your ethnic origin, using the 2001 Census classification (This is not about nationality, place of birth or citizenship as UK citizens can belong to any of these groups)
WHITE: / British / MIXED RACE: / White and Black Caribbean
Irish / White and Black African
Any other White background / White and Black Asian
BLACK or
BLACK BRITISH: / Caribbean / Any other Mixed background
African / ASIAN or
ASIAN BRITISH: / Indian
Any other Black background / Pakistani
CHINESE / Bangladeshi
ANY OTHER ETHNIC GROUP / Any other Asian background
C: RELIGION / BELIEF
Please state your religion / belief below
No religion / Do not wish to answer
Page 1 of 1 / RAYSON HOMES LTD FORM No 01 – 1 – 32
EMPLOYEE DECLARATION OF SUITABILITY
Version 1.0 / Rayson Homes Ltd Updated 2012 / © R.N.H.A. 2010

A: EMPLOYEE PERSONAL DETAILS

Surname: / First Name:
Date of Birth: / Job Position:

B: DECLARATION OF SUITABILITY

Question

/

NO

/

YES

Dates / Details
Have you ever had a police warning, caution or conviction?
Have you ever had an ISA or Criminal Records Bureau check that suggests that you are unsuitable to work with vulnerable persons?
Have you ever been disqualified or prevented from being a Care Service Provider?
Have you ever been disqualified from any registration involved, either directly or indirectly, in the provision of a Care Service?
Have you ever been involved as owner or manager of a Care Home or Care Service whose registration was refused or cancelled?
Have you ever had a financial interest in a Care Home or Care Service whose registration was refused or cancelled?
Have you ever been referred to the Vulnerable Adults List or the Children’s Barred List?
Have you ever had registration as a Care Service Provider refused or cancelled?
I confirm that the answers to these questions are true and accurate to the best of my belief and knowledge.
I also understand that it is my responsibility to declare any offences or orders which may affect my initial and/ or continued suitability to care for vulnerable persons.
Signature: ______Full Name (PRINT): ______Date: ______
Page 1 of 2 / RAYSON HOMES LTD FORM No : 01 – 4 – 00
DECLARATION OF HEALTH & MEDICAL FITNESS
Version 1.0 / Rayson Homes Ltd Updated 2012 / © R.N.H.A. 2010

Confidential Medical Questionnaire

Details
Name: / Forename(s):
Address: / Date of Birth:
Tel. No:
GP Name & Address:
A: Do you have, or have you ever suffered from, the following:
Condition / No / Yes
Dates / Details
Typhoid / Paratyphoid Fever, Enteric Fever?
Salmonella Infection?
Diarrhoea / Vomiting for more than 2 days?
Frequent Infections of the Upper Respiratory Tract, Colds, Sinusitis, Sore Throat, etc?
Severe Chest conditions, such as chronic Bronchitis with Phlegm, Pleurisy, Tuberculosis (TB)?
Discharge from the Ear / Eyes / Nose?
Problems with the Heart and / or Circulatory System, such as Angina, Abnormal Blood Pressure, Anaemia?
Problems with Sight or Hearing, such as Colour Blindness, Hard of Hearing?
Skin Rash / Eczema / Dermatitis / other Skin Disease?
Recurrent Boils / Styes / Septic Fingers?
Fits or Blackouts?
Migraines and other Severe Headaches?
Mental Health problems, such as Stress, high blood pressure, Addictions, Depression or Anxiety Attacks?
Page 2 of 2 / RAYSON HOMES LTD FORM No : 01 – 4 – 00
DECLARATION OF HEALTH & MEDICAL FITNESS
Version 1.0 / Rayson Homes Ltd Updated 2012 / © R.N.H.A. 2010
Confidential Medical Questionnaire Name ______
Condition / No / Yes
Dates / Details
Have you been an in-patient or out-patient at a hospital within the last 5 years?
Have you had treatment for any condition relating to the abuse or misuse of alcohol or drugs within the last 5 years?
Do you regularly take any type of prescription medication?
Have you ever suffered from a back strain, slipped disc, or other conditions of the back, joints or ligaments?
Are you registered disabled?
Have you ever been refused a Drivers’ Licence through health reasons?
Have you ever had medical insurance refused, or offered subject to special conditions?
Have you ever been refused employment, or had your employment terminated for health reasons?
Have you ever had MRSA (including positive MRSA swabs)
Clostridium Difficile (C Diff)
Hepatitis
Chicken Pox and / or Shingles / Y / N
Y / N
Y / N
Y / N
Give details of your Immunisation Record (including tetanus):
Are you prepared to undergo a medical examination? / YES / NO
Do you give your consent for us to contact your GP? / YES / NO
Any other relevant information:
I confirm that the answers to these questions are true and accurate to the best of my belief and knowledge.
Signature: ______Full Name (PRINT): ______Date: ______