Please Complete in Full, Legibly and in Black

Please complete in full, legibly and in black

Please complete in full, legibly and in blank ink or type

POST TITLE:

/

LOCATION/HOME:

PERSONAL DETAILS

Title (please tick) Mr Mrs Miss Ms / SURNAME:
ADDRESS: / FORENAME(S)
Telephone No (Home)
Telephone No (Mobile)
POST CODE: / Email address:
NI Number:
Do you require a work permit? / Yes No / (if yes, please state Ref. No. and expiry date)
Due to the nature of our business we can only employ people aged 18 and over. Are you aged 18 or older? / Yes No
Do you hold a full UK driving licence? Yes No / Have you held this for longer than 12 months? Yes No
Is your licence clear of endorsements? Yes No / If no, provide details:
Do you own your own car that could be used for business use? Yes No
How did you hear about us? (e.g. website, job advert etc.):
Seeking: Full time or Part time / If part time How many hours per week are you wanting to work?
If you are applying for a Support or Senior Support Worker role, you will be required to undertake ‘Sleep-in’ shifts. Are you able to undertake a minimum of 3 per month? / Yes No

REFEREES

Please indicate below the names and addresses of two referees, one of whom should be your current employer (if unemployed, most recent employer). Wherever possible, the second reference should also be employment related. Your referees should not be relatives.

1 / Name / 2 / Name
Address / Address
Telephone Number / Telephone Number
e-mail Address / E-mail Address
Is this a previous employer? / Yes / No / Is this a previous employer? / Yes / No
May we approach prior to interview? / Yes / No / May we approach prior to interview? / Yes / No
Were you known by any other name by these referees? /

Yes

/

No

(If yes, please give details)

EDUCATION AND TRAINING

School/College/University / From / To / Qualifications Obtained (Including Grade)

PROFESSIONAL TRAINING/QUALIFICATIONS/FURTHER TRAINING

(If application is in respect of a post requiring statutory registration or a professional qualification, successful candidates will be required to produce current registration certificates prior to commencement of employment).

Qualification / From / To / Date
Attained / Reg/PIN No
(if applicable) / Renewal Date
(if applicable)

(Please continue on a separate sheet if necessary)

Any Other Membership of Professional Bodies

EMPLOYMENT HISTORY:

Please provide full details of all employment (paid and voluntary) that you have undertaken starting with the most recent first. Please ensure all gaps in employment are detailed and explained.

Name and Address of Employer / Post Title / From / To / Reason for Leaving

Please state whether you would intend to continue in any other employment Yes No

QUESTIONS/SCENARIOS (Continue on a separate sheet if necessary)

1. Describe a situation where you have worked as part of team to achieve a common goal.
2. Describe a situation where you had to use your initiative.
3. Give an example of when you have diffused a difficult situation.
4. What do you think the job entails?

REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the work concerned, this post is exempt from the provisions of section 4(2) of the Rehabilitation of Offenders Act 1974. You are not entitled to withhold information about convictions which, for other purposes, are ‘spent’ under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation to your application for this post. Failure to disclose convictions, including ‘spent’ ones, if applicable, will result in disqualification or dismissal.

Police Records Check: - Prior to taking up any offer of employment with the Company, you will be asked to provide a satisfactory police check (an enhanced disclosure from the Criminal Records Bureau). This document must be supplied by you at your own expense.

Do you have a portable DBS? Yes No

Have you at any time received a court conviction, reprimand/caution? Yes No (if yes, please give details)

Date / Court / Details / Court Decision

ADDITIONAL INFORMATION

Have you had any disciplinary proceedings? / YES / NO
(if yes, please describe)

DECLARATION

I declare that the information on this form is true and complete and that any false information may result in an offer of employment being withdrawn, or my dismissal if discovered after my commencement with the Company. I understand that any information given may be held on a computer and paper filing system and thereafter falls within the provisions of the Data Protection Act.

Signature / Date

Where applications are submitted via email, your email will be accepted as your signature to the above declaration.

Please return completed application form to: - Recruitment Team

Millennium Care Services Limited

Millennium House

Station Lane

Featherstone

WF7 5BA

E-mail:

If you have not heard from us within 4 weeks please assume you have not been shortlisted.

For management use only: this section must be completed by both the shortlisting and interview panels
SHORTLISTED / YES / NO / Reasons for exclusion:
APPOINTED / YES / NO / Reasons for non-appointment:

With not for / Inclusive / Developing Potential / Responsive / Making a Difference