Application Form
Home Support Worker
Instructions to candidates:
Please complete each section and return the form or post to
Torrington Community Hospital, Calf Street, Torrington, EX38 2QE
- Personal Details
Surname:
Forename/s:
Address:
Postcode:
Telephone (home):
Mobile Number
Email:
Do you have a full clean driving licence?: / Yes / No
Do you have your own transport (or access to transport for work purposes?: / Yes / No
- Availability
Please indicate in the chart below when you ARE available for work (please tick).
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Morning
Afternoon
- Current and Previous Employment
Please put your most recent employer first.
Employers Name / Period of Employment / Job Title / Brief Description of duties
- Education
Most recent first please.
School/College/University / From – To / Qualifications
- Other Courses or Training
Course Title / Qualification / Year Completed
- Other Relevant Activities / Personal Interests
- Experience, Knowledge and Skills
Using the Job Description for this post to guide you, briefly outline the experience, knowledge and skills you will bring to this post.
- References
Please give the names and addresses of two people we can approach for a reference, one of whom should be indicate as your present or most recent employer.
Name:
Address:
Postcode:
Telephone No:
How do you know them? / Name:
Address:
Postcode:
Telephone No:
How do you know them?
Do you consent to us approaching your referees prior to interview? Yes / No
- Declaration of Offences
Because of the nature of the work for which you are applying, under the Rehabilitation of Offenders Act 1974 (Exemption Order 1975) you are not entitled to withhold information about any criminal convictions you might have, including those committed whilst a juvenile, which for other purposes may be regarded as ‘spent.’ Whilst a criminal conviction in itself is not necessarily a bar to employment, certain convictions may prohibit your employment.
Have you ever been convicted of a criminal offence? YES / NO if yes, outline below.
DateOffence/sCourt Disposal (sentence)
.
- Personal Declaration
I confirm that to the best of my knowledge the information given on this form is true and correct and can be treated as part of any subsequent contract of employment. Any information later found to be false may result in dismissal.
Signed………………………………………
Print Name…………………………………
Date…………………………………………
EQUAL OPPORTUNITIES MONITORING FORM (CONFIDENTIAL)
As part of its Equal Opportunities Policy Ageing Well aims to ensure that no applicant receives less favourable treatment, for example because of their age, ethnicity or gender.
In order to monitor the effectiveness of our recruitment practice your co-operation is appreciated in voluntarily providing the information requested below. It will NOT be used to shortlist candidates and this form will be separated from your application on receipt and its contents remain confidential. Should you not wish to complete it, this will in no way affect your application.
Please tick or fill in as appropriate.
GENDER
Male
Female
AGE
Please state ………….……
ETHNIC GROUP / RACIAL ORIGINS
(Please tick one category or fill out your own definition)
White European
White other (please specify)
Black Caribbean
Black African
Black other (please specify)
Indian
Pakistani
Bangladeshi
Chinese
Own definition………………………………………………..
DISABILITY
Do you consider yourself to have any form of disability?YES / NO
Are you Registered Disabled?YES / NO
CURRENT EMPLOYMENT STATUS
Are you currently:
employed / self employed / unemployed / student / parenting / other
…………………………………………………………………………………………………
ADVERTISEMENT OF THIS POST
Where did you see this post advertised?…………………………………………………
Thank you for your co-operation.
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