HELP-at-HOME SCHEME ~ APPLICATION FORM

Thank you for your interest in applying to be a helper with Age UK Mid Hampshire. Our helpers play a vital role in the work we do with the older people that we serve in Winchester, Andover and the surrounding area. The information you provide will be stored in confidence under the provision of the Data Protection Act and will be held securely and confidentially.

Title: / Mr / Mrs / Ms / Miss / Other
First Name:
Family/Surname:
Address:
Postcode:
Telephone No: / Mobile:
email:
Which position are you applying for?: / Cleaner/Helper Gardener/Light Maintenance Both

Previous experience relating to the post applied for:

What time/days do you consider you will be looking to work as a HAH helper:

Monday / Tuesday / Wednesday / Thursday / Friday / Weekends
am / am / am / am / am / am
pm / pm / pm / pm / pm / pm

Employment:

Current employer:
Position held:
Address:
Start Date:
Do you intend to stay in this employment:
Previous employer:
Position held:
Address:
Start Date:
Date employment ceased:

References:

Please provide details of two people you have known well (not relatives) for at least a year. Please provide someone you have previously worked with/for – an employer or professional person.

(1) Name:
Address:
Postcode:
Relationship to you:
Telephone No:
email: 
(2) Name:
Address:
Postcode:
Relationship to you:
Telephone No:
email: 
Do you hold a full and clean UK Driving Licence?: / Yes No
Do you have your own transport?: / Yes No

Please Note:

To enable you to help our clients, it is preferred that you are a car owner/driver.

Rehabilitation of Offenders Act 1974 (Exemption) Order 1975 (Amendments) Order 1986:

The provisions relating to the non-disclosure of criminal convictions do not apply to the position for which you are applying; therefore it is necessary for you to disclose any criminal convictions even if, under the Rehabilitation of Offences Act, they would otherwise be regarded as spent.

Have you been convicted of any criminal offence at any time?: / Yes No
If YES, please give details of the conviction(s) and date(s), using a separate sheet of paper.

Declaration:

I declare that the statements I have made in this application are accurate and true to the best of my knowledge and belief and I agree to inform the Help-at-Home Co-ordinator or Age UK Mid Hampshire office if any of these statements change.

DBS Check:

I also agree to an Enhanced Disclosure and Baring Service check being made in regard to possible criminal records, and understand that should there be any reason why I may not work as a helper with Age UK Mid Hampshire, as a result of an adverse disclosure, I will be asked to pay for the cost of the DBS application. I further understand that should I decide to leave Age UK Mid Hampshire within six months, I will be asked to pay for the full cost of the DBS disclosure.

I understand that this is a paid self-employment role and all work received will be co-ordinated by Age UK Mid Hampshire. Age UK Mid Hampshireis not responsible for ensuring that I make provision to pay my own tax and/or National Insurance Contributions.

Should I use my car to transport a client, I agree that I will have given the Age UK Mid Hampshire office copies of my car insurance policy and valid driving licence.

If I agree to undertake food preparation, I agree to attend a Food Safety course arranged through Age UK Mid Hampshire.

Signed: / Date:
Name:

Please return your completed application form to:
Help-at-Home co-ordinator or by post to:
Age UK Mid Hampshire, Westgate Chambers, Staple Gardens, Winchester, Hampshire SO23 8SR

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