We Care Because You Matter

Bas0412

MD HEALTHCARE LTD

We Care Because You Matter

Movilla House, 2 Berkshire Road, Newtownards, BT23 7HH

APPLICATION FORM Ref No: 11 / 13 / MD / 05 / ______Closing date: Friday 22 November 2013 @ 5pm

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

POSITION applied for: Healthcare Assistant Location : Aughnacloy House, Lurgan

Posts available:Full Time & Part Days (Permanent & Temporary to cover maternity leave)

Part Time Twilight shift (Permanent) & Bank Hours

Where did you see this advert? ...... ……...... ….………………….

Have you worked as an Agency Worker for our company in the last 3 months? …………………………………………

If Yes, what agency? …………………………………………………………………………….……………………………………………………

Have you applied for this position or worked for this company before? …………………………......

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

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

Please state all previous addresses including GB where appropriate.

Attach further addresses as necessary.

Address 1

Address 2

1 PREVIOUS EMPLOYMENT

Please list full employment history beginning with present/most recent

a) Please explain:

• Reason for gaps in employment
• Reason for limited work history

2REFERENCES

Please name two referees which must include your present/most recent employer.

Relatives should not be named as referees. Complete in full.

Do you give us permission to contact your referees before interview? Yes / No

3CRITERIA

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

Demonstrate how you fulfil the Essential Criteria (Please refer to Personnel Specification)

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Demonstrate how you fulfil any of the Desirable Criteria? (Please refer to Personnel Specification)

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______

4Please detail any exams/qualifications/courses

5INTERESTS /ACTIVITIES

Please detail any other activities which may be of interest in relation to your application:

______

6DRIVING INFORMATION

If the job you are applying for involves driving please complete the following. All questions relevant to the job for which you are applying must be answered:

Driving Related Posts

Do you hold a current full driving licence? Yes / No

Have you any motoring offences/endorsements/pending prosecutions? Yes / No

If yes, please give details:

Community Care Department:

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

Transport Department: The questions in this box must be answered

How long have you held your driving licence for? ......

Give full details of any accidents or losses in the past 3 years including circumstances and approximate cost (if None, please state ‘None’):

Have you ever been refused insurance or been the subject of additional terms or conditions? Yes / No

If yes, please state reasons:

7ACCESS NI 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.

Please declare, with dates, any prosecutions pending, any convictions, cautions or bind-overs.

Include ‘spent’ convictions. If you leave anything out it may affect your application.

______

______

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8ADULT/CHILD/ISA

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

Yes / No

Give details including dates:

______

______

______

______

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9SOCIAL CARE WORKERS

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

If yes, please complete details below:

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

Please note that Social Care Workers 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.

Have you ever been reported to NISCC? Yes / No

Please give details including dates:

______

______

______

______

______

Disclosures from the applicant and Access NI will be reviewed for compatibility with the post.

10MONITORING

Please complete the enclosed Monitoring Form and place in a separate ‘Monitoring’ envelope provided.

Post your Application Form and envelope to the HR Department at the Company address on the first page.

11DECLARATION

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 or misleading or false information may provide grounds for withdrawal of offer or termination of employment.

• Satisfactory references, Access NI disclosures, evidence document checks and relevant registration checks.

• Registration with the NISCC at any time required by the Company.

I consent to a medical assessment/examination, if required to undertake such, the results of which must be satisfactory, to ratify my appointment.

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

We are an Equal Opportunities Employer