Application for Employment

Position applied for: / Date of application:

PERSONAL DETAILS

Name: / Date of Birth:
Address: / Email:
Telephone:
NI Number:

EDUCATION

School or College / Subjects and Grades / Year obtained
Further Education / Professional qualifications / Year obtained

Please list any qualifications you have relating to healthcare:

Qualification / Institution / Date Obtained

AVAILABILITY

Period of notice required by current employer:
Date available for work:
Do you hold a work visa?
Do you hold a current driving licence?
Do you own a car?
Are you available for day shifts?
Are you available for night shifts?
Are you available for weekend work?
Are you willing to occasionally work at other homes across the Heritage Group in Luton?

ELIGIBILITY

Are you legally eligible for employment in the UK?
Do you require a work permit to work in the UK?
If yes, do you hold a current and valid work permit?
Please state type of permit.
Are you related to any employee of Heritage Care Homes? If so, please give details.
Have you applied for any other post in Heritage Care Homes in the last year? If so, please give details.

EMPLOYMENT HISTORY

Please start with your most recent employer and continue on a separate sheet if necessary.

Name of Employer:
Dates of employment: / from- to-
Job Title:
Address:
Telephone Number:
Type of Business:
Final Salary:
Please outline your main responsibilities below:
Reason for leaving:
Name of Employer:
Dates of employment: / from- to-
Job Title:
Address:
Telephone Number:
Type of Business:
Final Salary:
Please outline your main responsibilities below:
Reason for leaving:
Name of Employer:
Dates of employment: / from- to-
Job Title:
Address:
Telephone Number:
Type of Business:
Final Salary:
Please outline your main responsibilities below:
Reason for leaving:
Name of Employer:
Dates of employment: / from- to-
Job Title:
Address:
Telephone Number:
Type of Business:
Final Salary:
Please outline your main responsibilities below:
Reason for leaving:
Name of Employer:
Dates of employment: / from- to-
Job Title:
Address:
Telephone Number:
Type of Business:
Final Salary:
Please outline your main responsibilities below:
Reason for leaving:
Name of Employer:
Dates of employment: / from- to-
Job Title:
Address:
Telephone Number:
Type of Business:
Final Salary:
Please outline your main responsibilities below:
Reason for leaving:

KNOWLEDGE, SKILLS AND EXPERIENCE

Please tell us why, having read the job description and/or person specification, you think you are suitable for this post. Please give the reasons for your application and highlight any relevant employment, voluntary work or personal interests that meet the requirements of the post. Please continue on a separate sheet if necessary.

INTERVIEW ARRANGEMENTS

Do you have a disability or a condition that requires special arrangements to be made for you to attend an interview? If so, please specify.

HEALTH CHECK

Question / Yes or No / If yes, please brief details and dates
Are you under regular care from your GP or Specialist?
Have you ever suffered from depression, anxiety, a stress-related condition or other nervous problem?
Severe headaches or migraine?
Hypertension / Hypotension Y / N
(high or low blood pressure)
Fits, convulsions or epilepsy?
Bronchitis, pneumonia or lung tuberculosis?
Asthma, hay fever, any allergies including antibiotics?
Recurrent sore throats, sinusitis or frequent colds?
Rheumatic fever or joint pains?
Gastric or duodenal ulcer, or frequent and prolonged indigestion
Have you been treated for weight gain or loss?
Dysentery, food poisoning or gastroenteritis?
Any kidney or bladder infections?
Gynaecological trouble causing absence from work?
Hernia (rupture)?
Heart disease or disability?
Prolonged or severe back or neck pain, or disc trouble including any back pain necessitating time off work?
Varicose veins or foot ailments?
Eye conditions or injuries?
Ear infections, deafness or ear discharge?
Eczema, dermatitis, Psoriasis or other skin conditions?
Diabetes or thyroid trouble?
Have you had any operations? If so please specify
Any other condition requiring hospital treatment as an in/outpatient?
Have you been awarded a disability pension or early retirement on health grounds?
Are you taking any medication or drugs?
Do you have any disability, disease or disorder that may affect your ability to do the job?
Do you smoke? If so how many per day?
Do you have any alcohol-related or drug-related health problems?
Number of days sickness absence in the last year, and causes:

Name and address of GP:

REHABILITATION OF OFFENDERS ACT 1974 – NOTICE TO OFFENDERS

Because of the nature of the work involved the post for which you are applying is excempt from Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act ( Exemption Order 1975). This means you are not entitled to withhold information relating to any convictions you may have had.

This information will be treated as confidential and will not necessarily preclude you from employment.

Do you have any cautions or convictions to disclose? YES / NO

If you answered yes above, please give details below and continue on a separate sheet if necessary.

If selected for interview you will be required to give authorisation for a Criminal Records Bureau Check to be undertaken by the Home on your behalf

DATA PROTECTION ACT 1998

We will use the information on this form for purposes related to your application and potential employment and to monitor our recruitment process. Any data about you will be held in secure conditions with access restrictions. We may check the information provided by you with third parties. We will not disclose information about you to third parties, unless the law permits us to do so. If you are unsuccessful, your application will be destroyed after six months. If you are the successful candidate, this form will be kept in your personnel file.

REFERENCES

Please give the full names and addresses (including postcodes) of two referees. One should be your current or most recent employer, or a representative from your school, college or university.

Referee One
Name: / Work tel:
Job Title: / Email:
Organisation name and address:
Relationship to you:
Referee Two
Name: / Work tel:
Job Title: / Email:
Organisation name and address:
Relationship to you:

DECLARATION

I confirm that, to the best of my knowledge, the information given on this application form is accurate and true. I understand that submitting misleading or false information in my application or at interview may result in the withdrawal of any offer of employment made or, if I am appointed, may constitute grounds for dismissal. I confirm that I consent to the processing of my data as outlined above. I give the employer the right to investigate all references

EQUAL OPPORTUNITIES MONITORING FORM

In accordance with its equal opportunities statement, the Company will provide equal opportunities to all employees and job applicants and will not discriminate either directly or indirectly on the grounds of race, colour, ethnic origin, nationality, national origin, sex, marital status, disability, sexual orientation, religion or age.

In order to enable the Company ensure compliance with its policy statement, a system of monitoring has been set up. We have only asked for your name so that monitoring can take place at the shortlisting or interview stage and at the appointment stage. Once an appointment has been made, the data given on this form will be stored on computer in an anonymous format and the form will then be destroyed.

You may, of course, decide not to answer one or any of these questions but if you do respond, all information provided will be treated in confidence and will be used solely by the Human Resources department for the purpose of providing statistics for equal opportunities monitoring. The monitoring form does not form part of your application and will therefore be detached from it on receipt and stored separately. You can always mail this form separately if you wish.

Thank you for your assistance in completing this form

Name:
Post title:
Gender: / Male
Female
Prefer not to say
Marital status: / Married
Single
Other
(please specify)
Prefer not to say
Sexual orientation: / Heterosexual
Homosexual
Bisexual
Transsexual
Prefer not to say
Disabilities / None
Physical disability
Mental disability
Prefer not to say
Age band: / Under 18
18 – 29
30 – 39
40 – 49
50 – 59
60 – 65
Over 65
Prefer not to say
Ethnic origin / White / English
Scottish
Welsh
Irish
British
Other white background
(please specify)
Mixed / White and
Black Caribbean
White and Black African
White and Black British
White and Asian
Other mixed background
(please specify)
Asian / Indian
Pakistani
Bangladeshi
British
Other Asian background
(please specify)
Black / Caribbean
African
British
Other black background
(please specify)
Religion: / Christian
Catholic
Jewish
Sikh
Muslim
Hindu
Buddhist
Rastafarian
None
Other religion
(please specify)
Prefer not to say

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