App Form 1 CCW/0215

Head Office Address: Movilla House, 2 Berkshire Road, Newtownards, BT23 7HH

Please note that CV's are not accepted. If necessary, you may add another page to your application.

POSITION / Community Care Worker / Location
Application Ref Number / 06 / 15 / OPT / 01 / Closing Date / Friday 21stAugust 2015 / @ 5pm

Where did you see this advert?

NI Jobs / Job Market / Company Website / Facebook
Care & Health / Refer a Friend / Open Day / Other
Uni/College Board / Leaflet Drop

Have you worked as an Agency Worker for our company in the last 3 months?Yes / No

Have you applied for this position or worked for this company before? Yes / No

If Yes, please give details and dates ………………………………………………………………………..……………………………………..

If offered employment when would you be available to start? …...... …………...………………………

Mr/Mrs/Miss/Ms (Circle)
Surname / Home Tel No:
(……………..) ………….. ………………………………………………
Forename / Mobile No:
Maiden Name / Email Address
NI Number
Current Home Address
…………………………………………………………………………….
…………………………………………………………………………….
County ………………………… Postcode ……..……………… / Next of Kin
Name …………………………………………………………….
Address ……………………………………………………………
Contact No …………………………………………………………..
Relationship …………………………………………………………..

Please indicate in this section how you meet the criteria for the job.

Do you have use of own mobile?Yes / No

Do you have a full driving licence?Yes / No

Do you have access to a car to drive for work purposes? Yes / No

If successful you will need car insurance which states ‘in connection with business’ or ‘for business use’

Tell us what experience you have of providing personal care for an elderly or disabled person. Please include examples of the care you have provided.

PREVIOUS EMPLOYMENT

From:
Mth/Yr / To:
Mth/Yr / Name and Address of Employer / Job Title / Reason for Leaving
Present/Most Recent Employer
Previous Employers
From / To /

Please give details of and provide explanation for any time you were not working

Mth / Yr / Mth / Yr

REFERENCES

Please name tworeferees which must include your present/most recent employer. Relatives should not be named as referees. We may seek references prior to offer of employment. Please complete in full.

  1. Present* / Most Recent Employer* ( delete*)
Name …………………………………………………….
Work Address .……………………………………………………
……………………………………………………………………………………
Postcode ……………………………………………………
Tel /Mobile No ..………………/......
Work Email ………………………………………………………………
In what capacity do you know this person?
………………………………………………………......
Company Name …………………………………......
Employment From …………………….. To: ………….………… /
  1. *(Previous Employer) or (Personal/Character)
Name ……………………………………………………..
*(Work) Address ..….……………………………………………….
……………………………………………………………………………………
Postcode …………………………………………………….
Tel /Mobile No …………………/......
*(Work) Email .……………………………………………………
In what capacity do you know this person?
………………………………………………………......
*(Company Name ) …………………………………......
*(Employment) From …………………….. To: ………….………

PRE-EMPLOYMENT CHECKS

Due to the services provided the majority of posts within the Company are governed by the Protection of Children & Vulnerable Adults (NI) Order 2003 and the Rehabilitation of Offenders (Exceptions) Order NI 1979. Disclosure of offences will not automatically debar you from applying for the post. The Company is willing to consider persons with a criminal record on their merits. You will be required to complete an application for an Access NI check if you are invited to interview. All information provided will be kept in the strictest confidence and only be used for the purposes of assessing your suitability for the post you have applied. A copy of the company Ex-Offenders Policy can be made available on request.

Do you have any convictions that are not “protected” as defined by the Rehabilitation of Offenders (Northern Ireland) Order 1978, as amended in 2014?

______

The Access NI Code of Practice is available from

Have you ever been the subject of an Adult or Child Abuse investigation or been previously referred to the Independent Safeguarding Authority/DBS as a result of misconduct involving a child or a vulnerable adult?

Yes / No

If yes, please give details including dates:

______

______

Please note that Social Care Workers and managers of SCW’s are required to be registered with NISCC.

If you are not already registered with NISCC you will be required to obtain registration for the purposes of employment within a caring role. This is mandatory for SCW staff in our Nursing Home and manager/co-ordinator/trainer level of Domiciliary. When registration becomes mandatory for Domiciliary Social Care Workers the relevant staff must also become registered.

Are you registered with the Northern Ireland Social Care Council (NISCC)? Yes / No

If yes, please complete details below. If no, you will be required to make an immediate application for NISCC registration on offer of employment where this is necessary for the post.

NISCC Reg No: ______Part of Register ______Expiry Date ___/___

Have you ever been reported to NISCC? Yes / No

Please give details including dates:

______

______

All disclosures will be reviewed for compatibility with the post.

MONITORING

Please complete the enclosed Monitoring Form and place in the Monitoring Envelope provided. Send this back with your application form to the HR Department at the Company address on the top of the first page.

If you are disabled please give details of any special arrangements you would require for interview.

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

DECLARATION

I understand and accept that any offer of employment and subsequent appointment will be subject to:

  • Information I give being correct and that any omissions , misleading or false information may provide grounds for withdrawal of offer or termination of employment.
  • Satisfactory references, Access NI disclosures, evidence document checks, medical information and relevant registration checks as deemed acceptable to the company
  • Registration with the NISCC at any time required by the Company.

Signature ...... Date ……..../………./………….

We are an Equal Opportunities Employer