Application Pack
Home Care Professionals
Personal Details
Title:
Surname:
First name:
Middle name(s):
Date of birth:
Gender:
Female
Male
Others
House name or no:
Start of residence (date):
Street:
Tel (home):
Town:
Tel (work):
County:
Tel (mobile):
Postcode:
Country:
Email:
Title of job you are applying for:
Select Job Role
HOME CARER
CARE CO-COORDINATOR
CARE ASSISTANT
SUPPORT WORKER
CV Upload:
Emergency Contact
Name:
Tel (home):
Relationship to you:
Tel (work):
Email:
Professional Registration
Are you registered with any professional bodies? (Please Tick)
HCPS (formerly HPC)
NMC
GMC
GPhC
RCCP
N/A
Registration number:
Expiry date/renewal:
Nationality & Eligibility to Work
Do you hold a British/EU passport?
Yes
No
Nationality:
Passport number:
Expiry date:
If you do not hold a British/EU Passport, do you hold any of the following?
Indefinite leave to remain in the UK
Ancestry visa
Work permit/sponsorship (Tier 2)
Spousal/partnership visa
Student visa (Tier 4)
Biometric residence permit
Working holiday visa/youth mobility (Tier 5)
Other (please specify):
Professional Qualifications
Qualification
Place where obtained:
Date to/from:
Certificate attached?
Professional References
Please give the names and contact details of 2 professional references from your current and most recent employment/education. Referees must have worked in a senior position to yourself. Please be aware that G & H Personnel are unable to offer you work until satisfactory references have been obtained.
Reference 1
Organisation:
Job title:
Ward/dept.:
Grade/band:
Dates employed (Month/Year):
Referee name:
Professional title:
Email:
Telephone:
Capacity in which known (i.e. Manager):
Reference 2
Organisation:
Job title:
Ward/dept.:
Grade/band:
Dates employed (Month/Year):
Referee name:
Professional title:
Email:
Telephone:
Capacity in which known (i.e. Manager):
Declaration of Criminal Record
Applicants for Healthcare positions are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare your prosecutions or convictions, including those that are ‘spent’ under this Act. Please tick.
1.Applicants for Healthcare positions are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare your prosecutions or convictions, including those that are ‘spent’ under this Act. Please tick.
Yes
No
2.Do you have any convictions, cautions, reprimands or final warnings which would not be filtered in line with the current guidance?
Yes
No
3.Have you had a Police Check in another country within the last 6 months? If so, please provide details below.
Yes
No
4.Have you ever been suspended or are you currently under investigation by the NHS Trust, professional body or any other organisation?tick.
Yes
No
If yes, please provide details:
5.Have you ever had an Enhanced Disclosure and Barring Service (DBS) check? (formerly Criminal Records Bureau check or CRB)
Yes
No
Disclosure number:
Date:
Company that conducted the check:
If you have signed up do the DBS Update Service, please provide details of the DBS number:
The company will undertake an Enhanced DBS check on your behalf. You will not be placed without having a current DBS check. This process will be explained and will be completed if your application is successful.
Declarations
Working Time Directive
The Working Time Regulations 1998 require the company to limit your average weekly working time to 48 hours, unless you agree that the limit shall not apply to you. If you would like to work more than 48 hours, you can opt out below:
I agree that I may work for more than an average of 48 hours a week (leave unticked if you do not agree to this)*
*If you change your mind, you also agree to give the company at least 3 months notice in writing to end this agreement.
I can confirm that I have read this document fully and that all the information provided is correct and to the best of my knowledge and belief. I give consent to contact referees regarding the information I have provided unless specified otherwise. I will inform the company should anything change, that might affect my position and I understand the information given on this form will be processed by computer and used for registration purposes, under the Data Protection Act 2018.
1. I understand that if I am at any stage charged or cautioned with a criminal offence after signing this declaration, I must inform the company immediately.
2. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my pre-employment health questionnaire.
3. I acknowledge and confirm that the company is authorised to apply for and obtain a Disclosure and Barring Service (DBS) check and references from any previous employers and educational establishments.
4. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future that the company may commence disciplinary action, resulting in up to and including dismissal, in line with its disciplinary policy.
5. I acknowledge that my personal details will be stored and handled correctly by the company in accordance with the Data Protection Act 2018, however, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents - DBS, Occupational Health, References).
6. I understand that if I am on a student visa, I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student changes I must inform the company.
7. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform the company.
8. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for the company, I must inform the company immediately.
9. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will inform the company if I am under investigation or suspended by my professional regulatory body or employer at any point while working for the company.
Signature (Typing Name is Acceptable):
Print Name:
Date:
SUBMIT