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We would be honoured to have you work with us. We provide equal employment opportunities for all.

SHS Application Form (01)

SHS Applicants Guide (v1)

Application Form

1Personal Details

2Education

3Previous Employment

4Formal Warnings

5Current Training

6References

7Equal Opportunities Monitoring

8Health Questionnaire

Position Applied For *

Personal Details

Surname *

First names *

Previous Names

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Home Telephone No. *

Work Telephone No. *

Mobile No. *

National Insurance Number *

Immigration Details

Are you a citizen of the EU? *

Do you need a work permit? *

Current driving licence? *

Do you have a car for work use? *

1. School/Further Education/Higher Education

Schools/FE/HE attended *

Examination Grade *

Year Obtained *

2. School/Further Education/Higher Education

Schools/FE/HE attended

Examination Grade

Year Obtained

3. School/Further Education/Higher Education

Schools/FE/HE attended

Examination Grade

Year Obtained

A full employment history must be detailed beginning with your current employment and covering all reasons for gaps in any given year.

Most Recent/Last Employment

Start Date *

End Date *

Employer’s name *

Employer’s Phone *

Employer's Email *

Position Held *

Salary & Benefits *

Reason for leaving *

Employment prior to the above

Start Date

End Date

Employer’s name

Employer’s Phone

Employer's Email Address

Position Held

Salary & Benefits

Reason for leaving

Employment prior to the above

Start Date

End Date

Employer’s name

Employer’s Phone

Employer's Email Address *

Position Held

Salary & Benefits

Reason for leaving

Please detail any disciplinary action within the previous 3 years, including any current, “live” formal warnings *

REHABILITATION OF OFFENDERS ACT 1974 – NOTICE TO OFFENDERS

Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)
The amendments to the Exceptions Order 1975 (2013) provide that certain convictions and cautions are protected and are not subject to disclosure to employers and cannot be taken into account

Do you have any convictions to disclose? *

Any information about convictions, cautions, reprimands or final warnings. This information will be treated as confidential and will not necessarily preclude you from employment. *

Declaration. Failure to declare or the falsification of any of the above details will result in the withdrawal of any job offer. *

I declare that the above details are not falsified.

Statement of your personal qualities and any experiences which is relevant to the post *

Please give details of any mandatory training courses completed, along with dates completed and expiry dates.

CURRENT TRAINING

Moving and Handling

Date Completed

Expiry Date

CURRENT TRAINING

Safeguarding Adults

Date Completed

Expiry Date

CURRENT TRAINING

Safeguarding Children

Date Completed

Expiry Date

CURRENT TRAINING

Infection Control

Date Completed

Expiry Date

CURRENT TRAINING

Health and Safety

Date Completed

Expiry Date

CURRENT TRAINING

Fire Safety

Date Completed

Expiry Date

CURRENT TRAINING

Basic Life Support / Resuscitation

Date Completed

Expiry Date

CURRENT TRAINING

Preventing Radicalisation

Date Completed

Expiry Date

CURRENT TRAINING

Conflict Resolution

Date Completed

Expiry Date

CURRENT TRAINING

Data Security Awareness

Date Completed

Expiry Date

CURRENT TRAINING

Equality, Diversity and Human Rights

Date Completed

Expiry Date

Details about any additional courses you have undertaken relevant to Health and Social Care. (For example PMVA, PBS or ProAct Scip)

Please give the name and address of two referees, one of whom must be your current or most recent previous employer. References from relatives or friends are not accepted.

1. Reference

Referral Name *

Status *

Referral's Email *

Address *

Telephone Number *

2. Reference

Referral Name *

Status *

Referral's Email *

Address *

Telephone Number *

3. Reference

Referral Name

Referral's Email

Status

Address

Telephone Number

This organisation seeks to work in a flexible and family friendly manner with its staff, however unsocial hours are part and parcel of a quality care service. Weekend working is a requirement for all staff, the frequency of which will be determined at interview.

Please indicate holiday dates if already booked

Period of notice required in present post

Earliest start date *

This section of the application will be detached and used for monitoring purposes only. Our organisation recognises and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect in line with the Equality Act 2010 legislation. We welcome applications from all sections of the community.

Date of Birth *

Gender *

Male
Female
I do not wish to disclose this

Race Relations (Amendment) 2000

I would describe my ethnic origin as (please tick):

Asian or Asian British

Bangladeshi
Indian
Pakistani
Any other Asian background

Black or Black British

African
Caribbean
Any other Black background

Mixed Raced

White & Asian
White & Black African
White & Black Caribbean
Any other missed background

White

British
Irish
Any other white background

Other Ethnic Group

Chinese
Any other ethnic group
I do not want to disclose this

Sexuality

Please select the option which best describes your sexuality. *

Lesbian
Gay
Bisexual
Heterosexual

Religion or belief

Please indicate your religion or belief *

Atheism
Buddhism
Christianity
Islam
Jainism
Sikhism
Judaism
Hinduism
Other
I do not wish to disclose this

To be used for those applicants that have been deemed appointable).

To comply with the Equality Act 2010, please complete this questionnaire as fully as possible. Failure to do so could impede or delay your appointment. All information is confidential.

Have you ever had or suffered from?

Epilepsy/Blackouts *

Nervous Mental Disorders *

Migraine/Headaches *

Sensory Impairment *

Skin Allergies *

Back pain/Previous Back Injury *

Heart Condition *

Asthmatic or respiratory ailments *

Recurring Incidence of Illness *

Are you registered disabled? *

Please detail

Please List Below any Periods spent Outside of the United Kingdom as a Resident (do not include holidays)

1. Period Spent Outside the UK

2. Period Spent Outside the UK

3. Period Spent Outside the UK

Vaccinations or immunisations

Please List below any vaccinations or immunisations

1. Vaccinations or immunisations

Date

Immunisation

Expiry

2. Vaccinations or immunisations

Date

Immunisation

Expiry

3. Vaccinations or immunisations

Date

Immunisation

Expiry

Final declaration *

I declare that the information given is correct to the best of my knowledge. In my view, I am fit physically and mentally to undertake this post. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references.

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Personal Details

Immigration Details

1. School/Further Education/Higher Education

2. School/Further Education/Higher Education

3. School/Further Education/Higher Education

Most Recent/Last Employment

Employment prior to the above

Employment prior to the above

REHABILITATION OF OFFENDERS ACT 1974 – NOTICE TO OFFENDERS

1. Reference

2. Reference

3. Reference

Race Relations (Amendment) 2000

Sexuality

Religion or belief

To be used for those applicants that have been deemed appointable).

Vaccinations or immunisations

1. Vaccinations or immunisations

2. Vaccinations or immunisations

3. Vaccinations or immunisations

Contact Information

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