Abbeyfield & Wesley welcomes applications from all sectors of the community irrespective of age, race, religion, sex, sexual orientation or disability. The information requested in this form is to enable us to obtain a rounded picture of you. Personal information will not of itself be used to disqualify your application.

This post involves substantial access to vulnerable adults and children, therefore, as part of the selection process, Abbeyfield & Wesley requires an Enhanced Disclosure Check to be carried out through Access NI. Following interview, the preferred candidate will be offered the post subject to satisfactory Enhanced Disclosure Check. This will include verification of identity and a report on the preferred candidate's full criminal history (including spent and unspent convictions), cautions, disqualifications from regulated or care positions, and any other material considered by the police to be relevant to the position applied for. A criminal record will not necessarily be a bar to obtaining a position (if you require further information please request a copy of the Abbeyfield & Wesley Policy on Recruitment of those with a Criminal Record. You can access further information and the Access NI Code of Practice on

a) Mr/Mrs/Miss Ms Surname: ______Forenames ______

Address: ______

______Post Code: ______

Telephone Numbers: (Home): ______(Work): ______

(Mobile): ______Email Address: ______

b)Do you have a clean, current driving licence? Yes No

Do you have access to a car or are you able to fulfil any driving Yes No

requirements for this position?

c)Are you related to any employee or Board Member of

Abbeyfield & Wesley, or are you a previous employee? Yes No

If yes, please provide details:

______

a) Do you require communication in:-

Large Print ElectronicAudio BrailleOther

If yes, what would you like? ______

b)Should you be required to attend for interview, do you need any reasonable adjustments/ arrangements?

Yes No If yes, what do you need? ______

Do you require a permit/visa to work in the UK? Yes No

If yes, do you hold a permit/visa to work in the UK? Yes No

If yes, state start/finish dates and any restrictions that apply to this permit/visa:-

Please list any educational or other qualifications, or other relevant training.(Continue on separate sheet if necessary).

Detail of examinations/qualifications/courses

a)Present or Most Recent Employment:

Job Title: ______

Employer Name/Address: ______

______

______

Dates of Employment: From: ______To: ______

Brief outline of duties:

______

______

______

______

______

______

______

______

______

Why do you wish to leave your present employment?

______

______

______

What period of notice does your current employer require?______

______

b) Past Employment (over the past 10 years)

Please tell us about other jobs you have had, starting with the most recent. Please include periods of unemployment, unpaid placements and voluntary work.(Continue on a separate sheet if necessary).

______

Briefly describe how you meet the person specification of this position. (Continue on a separate sheet if necessary)

______

______

______

______

______

______

______

Please give the full names and addresses of 2 referees, one of whom should be your present or most recent employer. References from relatives will not be accepted.

Referee 1

Full Name: ______Job Title: ______

Relationship (Please circle as appropriate) Employer/Other ______

(If other, state relationship)

Address: ______

______Post Code: ______

Telephone No: ______Mobile No: ______

Fax No: ______Email: ______

May we contact prior to interview? (Please tick)YesNo

Referee 2

Full Name: ______Job Title: ______

Relationship (Please circle as appropriate) Employer/Other ______

(If other, state relationship)

Address: ______

______Post Code: ______

Telephone No: ______Mobile No: ______

Fax No: ______Email: ______

May we contact prior to interview? (Please tick)YesNo

The Association reserves the right only to interview on the basis of information supplied on the application form by candidates who meet the criteria established for the post. Your application will be held in a normal filing system following the closing date for applications. After a certain period, the file will be destroyed in accordance with Abbeyfield & Wesley Housing Association’s document retention policy.

Please note any other information that would support your application(Continue on a separate sheet if necessary)

______

______

______

______

Job MarketNewspaper Other(specify) ______

I give the employer the right to investigate all references and to secure additional job related information about me.

I have read and understood the requirements and particulars of the appointment which have been supplied to me.

I further understand that the job offer may be subject to satisfactory references, a pre-employment health assessment, and a satisfactory Enhanced Disclosure Check.

I am not aware of any reason why I cannot work in a regulated activity.

FOR CARE POSITIONS ONLY

I further understand that I must already be registered as a Care Worker with the Northern Ireland Social Care Council and this will also involve a Police Check on criminal records/cautions.

WARNING: By completing and signing this application form you are consenting to the information on your application being held as outlined above. This information will not be disclosed to a third party unless requested to do so under law. Any applicant found to have knowingly give false or incorrect information or to have wilfully failed to disclose any relevant fact, will be excluded from the recruitment process or dismissed. Canvassing will disqualify.

DECLARATION OF CONSENT

Signature of Candidate:______

Date of Signing: ______

Please return by 23rd February 2018:

Human Resources Dept, Abbeyfield & Wesley, 2 Wesley Court, Carrickfergus, BT38 8HS

Or


Guidance Notes

We are an Equal Opportunities Employer. We aim to provide equality of opportunity to all persons regardless of their religious belief; political opinion; sex; race; age; sexual orientation; or, whether they are married or are in a civil partnership; or, whether they are disabled; or whether they have undergone, are undergoing or intend to undergo gender reassignment.

We do not discriminate against our job applicants or employees on any of the grounds listed above. We aim to select the best person for the job and all recruitment decisions will be made objectively.

In this questionnaire we will ask you provide us with some personal information about yourself. We are doing this for two reasons:-

Firstly, we are doing this to demonstrate our commitment to promoting equality of opportunity in employment. The information that you provide us will assist us to measure the effectiveness of our equal opportunity policies and to develop affirmative or positive action policies.

Secondly, we also monitor the community background and sex of our job applicants and employees in order to comply with our duties under the Fair Employment & Treatment (NI) Order 1998.

You are not obliged to answer the questions on this form and you will not suffer any penalty if you choose not to do so.

Nevertheless, we encourage you to answer the questions. Your identity will be kept anonymous and your answers will be treated with the strictest confidence. We assure you that your answers will not be used by us to make any unlawful decisions affecting you, whether in a recruitment exercise or during the course of any employment with us. To protect your privacy, you should not write your name on this questionnaire. The form will carry a unique identification number and only our Monitoring Officer will be able to match this to your name.

POST: SENIOR NIGHT CARE ASSISTANT Monitoring Number: PCH SNCA/PCH/FEB18

Regardless of whether we practice religion, most people in Northern Ireland are seen as either Roman Catholic or Protestant. If you do not complete this questionnaire, we are encouraged to use a residuary method to make a determination on the basis of personal information on the file/application form.

COMMUNITY BACKGROUND: (please tick)

ProtestantRoman CatholicIslamicBuddhism

HinduismJudaismSikhism Other (specify) ______

SEX:

Please indicate your sex by ticking the appropriate box: Male Female

Note: If you answer these questions about community background and sex you are obliged to do so truthfully, as it is a criminal offence under the Fair Employment (Monitoring) Regulations (NI) 1999 to knowingly give false answer to these questions.

AGE: Please state your date of birth: ______

RACIAL GROUP:Please state your nationality: ______

Please indicate your race or colour or ethnic or national origins:

White ChineseBlack Caribbean

Irish TravellerIndianBlack African

PakistaniBangladeshiBlack Other

Mixed ethnic group (please state which): ______

Any other ethnic group (please state which): ______

DISABILITY:

Under the Disability Discrimination Act 1995 a person is deemed to be a disabled person if he or she has a physical or mental impairment which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. Please note that it is the effect of the impairment without treatment which determines whether an individual meets this definition:

Do you consider that you are a disabled person? Yes No

If you answered “yes”, please indicate the nature of your impairment by ticking the appropriate box or boxes below:

Physical impairment, such as difficulty using your arms, or mobility issues requiring

you to use a wheelchair or crutches:

Sensory impairment, such as being blind or having a serious visual impairment, or being

deaf or having a serious hearing impairment:

Mental health condition, such as depression or schizophrenia:

Learning disability or difficulty: such as Down’s Syndrome or dyslexia, or

cognitive impairment, such as autistic spectrum disorder:

Long-standing or progressive illness or health condition, such as cancer, HIV infection,

Diabetes, epilepsy or chronic heart disease:

Other (please specify): ______

SEXUAL ORIENTATION:

Please indicate your sexual orientation by ticking the appropriate box below:

My sexual orientation is towards:

Persons of a different sex to me:Persons of the same sex as me:

(ie I am a heterosexual man or woman)(I am a gay man or a lesbian)

Persons of both sexes:

(ie I am a bisexual man or woman)

MARITAL STATUS:

Please tick the appropriate box below which defines your marital status:

Married/Civil Partnership Single Divorced Other

DEPENDANTS/CARING RESPONSIBILITIES:

Do you have dependants, or caring responsibilities for family members or other persons?

YesNo

If you answered “yes”, please indicate whether your dependants or the people you look after are:

(Please tick the appropriate box or boxes):

A child or children:A disabled person or persons:

An elderly person or persons:Other:

If “Other”, please specify: ______