“Opening hearts and minds”

Head Office Postal Address

96 Bilton Road, Rugby, Warwickshire, CV22 7AT

Telephone: 02476 540935, Fax: 02476 545 519

Email:

Application for Employment

Pinnacle Care Ltd is an Equal Opportunities employer and your application for employment will be assessed solely on its merits. We welcome applications from all sectors of the community, irrespective of age, gender, ethnic origin, disability, religious belief or sexual orientation.

Position Applied for:

Personal Information

First Name: / Surname Name:
Date of Birth / National Insurance No
Home Tel No / Mobile No
Address / Have you attached Your CV?
Yes
No
Post Code:

References

Please provide details of two professional referees, one of whom must be you last, or latest, employer. Please note that character references will not be accepted.

Current or Latest Employer / 2nd Reference
Name
Position
Address
Post Code
Telephone No.
Email Address

Employment History

Please list previous employers (including details of any temporary employment held) current or most recent first, and account for any gaps in your employment. Continue on a separate sheet if necessary. If you have worked for Pinnacle Care Ltd before please identify the home you worked in.

Employer Name & Address / Dates / Job Title & Key Duties/Responsibilities
From / To

Rehabilitation of Offenders Act 1974

Employment in the Personal Care industry is exempt from the above act. Please list below any criminal convictions, warnings, cautions or reprimands including those that could be classed as ‘spent’ under the Act.

Please also include any offences committed outside the E.U.

Details of Conviction/Warning/Caution/Reprimand / Date of Conviction / Sentence

Declaration

Pinnacle Care Ltd stores and processes data in accordance with the Data Protection Act 1998. I understand that the details I have provided on this form and other associated documents will be stored and processed in accordance with Pinnacle Care Ltd’s recruitment procedures and with the requirements of the Care Quality Commission. In completing this form I give my consent for the details to be to be used for this purpose.

I declare that all forgoing details given in this application are true to the best of my knowledge. I understand that if I have knowingly provided false or withheld material information I may be dismissed from any post gained as a result.

Signature / Date

Please attach your current CV with this application

Application Form Jan 17 3