Page 1 of 4 Version 1.0e Last Up-dated February 2014 Heron Care Systems, Year 2014
Heron Care Unit F4 Helsby Court, Sinclair Way,PrescotBusinessPark, Prescot, Merseyside L34 1PB
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: ______Postcode: ______
Telephone Private: ______Business: ______Mobile: ______
Place of Birth: ______Nationality: ______Email address______
B: HEALTH & DISABILITIES
Do you have any disabilities which may be relevant to this Job Application? YES / NO
If so, please describe them: ______
Are you Registered Disabled? YES / NO RDP No: ______
Overall state of health: EXCELLENT / GOOD / POOR
Hearing: EXCELLENT / GOOD / POOR
Eyesight: EXCELLENT / GOOD / POOR SPECTACLES / CONTACT LENSES / NEITHER
Please give details of any medical condition for which you have received treatment in the past 3 years:
______
Have you had treatment for any condition relating to the abuse or misuse of drugs or alcohol within the last 5 years? YES / NO
If "YES" please provide brief details: ______
Are you prepared to undergo a medical examination? YES / NO
C: DRIVING RECORD
Are you a car owner? YES / NO Make / model / year: ______
Current Driving Licence: PROVISIONAL / FULL / PSV / NONE
Driving Licence valid from: ______to: ______
Details of current endorsements : ______
Have you ever been disqualified from driving, or had insurance refused? YES / NO
If "YES" please provide brief details: ______
Heron care Form No: 03-1-30 Page 2 of 4
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. Membership of Professional Organization
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. Also, as part of a wider Vetting & Barring Scheme to assess the risk of harm that a person may present to vulnerable persons we are required to undertake an Independent Safeguarding Authority (ISA) check through the Criminal Records Bureau to ensure satisfactory registration with the ISA of any person who is a Care Manager or Domiciliary 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.
You are required to pay a ten pound administration fee before your application will be sent if you are a successful candidate.
Heron care Form No: 03-1-30 Page 3 of 4
G: EMPLOYMENT HISTORYPlease provide details of all employment, beginning with your present or most recent job first
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 / ANY
If PART-TIME please indicate preferred hours: ______
This Post may Require sleep ins : ______
Details of any other work which you will continue to undertake if you are offered this Job Position:
Can you provide personal care to our client group;
Please provide details of any outstanding holidays to be taken:
AVAILABLE TO TAKE UP EMPLOYMENT FROM: ______
Heron Care Form No: 03-1-30 Page 4 of 4
J: REFERENCESPlease 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:
1. Name: ______
Address: ______
______
Telephone Number: ______
Email address: ______
Occupation: ______
2. Name: ______
Address: ______
______
Telephone Number: ______
Email address: ______
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: ______
Heron Care 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.
WE ARE AN EQUAL OPPORTUNITIES EMPLOYER
The sole criterion for selection of applicants will be suitability for the Job Position, regardless of age, gender, gender orientation, background, culture, ethnic denomination, religious affiliation, marital status or disability. This is in accordance with our declared
Equal Opportunities & Diversity Policy, No 106.
Form No: 03-1-35 EQUAL OPPORTUNITIES & DIVERSITY MONITORING
JOB APPLICANTS
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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 below
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 tick your religion / belief group
Christian / Muslim / Islam
Adventist / Sikh
Judaism / Rastafarian
Mormon / Zoroastrian / Parsi
Buddhist / Bahá’í
Hindu / No religion
Form No: 03-1-35 Page 2 of 2
Job Reference No: ______
D: DISABILITYThe Disability Discrimination Act, 1995, (DDA) provides for disabled people to have a legal right to fair treatment in employment matters. When answering this question please note that the DDA defines a disability as “a mental or physical impairment which has a substantial and long-term adverse effect upon a person’s ability to carry out normal day-to-day activities”.
Please tick the description(s) that you feel best describes your impairment:
NO DISABILITY / Unseen disability (e.g. diabetes, epilepsy, asthma)
Dyslexia / Autistic Spectrum Disorder (e.g. Asperger’s Syndrome)
Blind / Partially sighted / Personal Care Support
Deaf / Hearing impediment / Multiple disabilities
Wheelchair user / Mobility difficulties / Other mobility difficulty
Mental Health condition / Other disability
B: DECLARATION OF SUITABILITY
Question / NO / YES
Dates / Details
Have you ever had a 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/support worker?
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 Domiciliary Care Service whose registration was refused or cancelled?
Have you ever had a financial interest in a Domiciliary Care Service whose registration was refused or cancelled?
Have you ever been referred to the Vulnerable Adults List, Children’s Barred List, or previous lists (SOCA etc)?
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 continued suitability to care for vulnerable persons.
Signature: ______Full Name (PRINT): ______Date: ______
Form No: 03-1-38 EMPLOYEE DECLARATION OF SUITABILITY
Page 1 of 1 Version 1.0e Last Up-dated February 2014 Heron Care Systems, Year 2014