ASLOCKTON HALL NURSING HOME – CLAREGRANGE LTD
Aslockton Hall– New Lane, Aslockton
Nottinghamshire NG13 9AH
Telephone: 01949 850233
Email:

EMPLOYMENT APPLICATION FORM

POST APPLIED FOR:______
Where did you hear of this vacancy:______

PERSONAL DETAILS:

Surname: (Mr/Mrs/Miss/Ms)
Forenames:
Maiden/Former Name:
Address:
Home Telephone: Mobile:
Email:
Do you have a current driving licence: Yes/No
Do you have your own transport: Yes/No
Do you need a work permit: Yes/No
To comply with the Employment Equality(AGE) Regulations 2006, the post of Care Assistant holds a genuine occupational requirement that the applicant must be 18 years or over.
Please indicate this by ticking below:
I am aged 18 years or over:______

EQUAL OPPORTUNITIES POLICY

Aslockton Hall Residential and Nursing Home is committed to equal opportunities. We welcome employees and residents from all sections of the community. Any exceptions to this will be lawful and will comply with the Race Relations Act 1976 section 7 of the Sex Discrimination Act 1975 and the Employment Equality Age Regulations 2006. Employment will be given and service delivered regardless of age, gender, sexual orientation, marital status, religion, race, disability, colour, ethnic and national origin and nationality.

Employment Details:

Name and address of current employer / Job Title/Duties / Reason for leaving
Start date: / Salary/wage: / Notice required:

EMPLOYMENT HISTORY: Held in the last 10 years.

Name & Address of Employer: / Job title / Date Started / Date Left / Reason for leaving

EDUCATION AND TRAINING

Details of secondary education (Examinations/Grades):
Details of Higher Education: (Qualifications gained):
Professional Registration Number and Expiry Date:
Professional Education/Training Qualifications Gained (Which are relevant to position applied for):

Additional information

Please indicate any additional information you may wish to give in support of your application. Describe how you consider your past experience, training or outside interests may be helpful to you in this post.

PRESENT HEALTH

Do you have any disabilities that might affect your application?
Yes/No

Please tell us if:

  1. there are any reasonable adjustments we can make to assist you in your application
  2. there are any reasonable adjustments we can make to the job itself to help you carry it out

References

May we approach your present employer for a reference? ……………… Yes / No

If your reply “yes” please give a name and designation of the person who will supply this reference.

NAME: / DESIGNATION:

PLEASE GIVE DETAILS OF 3 PERSONS WHO SHOULD NOT BE RELATED TO YOU WHO HAVE CONSENTED TO ACT AS REFEREES ON YOUR BEHALF. 2 PERSONS SHOULD BE PROFESSIONAL REFEREES AND 1 SHOULD BE A PERSONAL REFEREE.

NAME …………………………………………………………….
ADDRESS ………………………………………………………...
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TELEPHONE ……………………………………………………..
JOB TITLE ……………………………………………………….. / NAME …………………………………………………………….
ADDRESS …………………...……………………………………
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TELEPHONE ……………………………………………………..
JOB TITLE ………………………………………………………...

PERSONAL REFERENCE

NAME ……………………………………………………………………………………………………………………………………..
ADDRESS ………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………
TELEPHONE ……………………………………… RELATIONSHIP TO YOU ………………………………………………………….
REHABILITATION OF OFFENDERS ACT 1974
Please give details of any criminal convictions against you. Because of the nature of the work for which you are applying, this post exempt from the provisions of the above act. You are therefore NOT entitled to withhold information about convictions which are “spent” under the act. (If appropriate please state “No convictions to declare”. A Disclosure and Barring Service (former Criminal Record Bureau) Check and Protection of Vulnerable Adults (POVA) check will be made prior to confirmation of employment.

DECLARATION:

I declare that the information given on this form is true and complete to the best of my knowledge and belief. I understand that if I am subsequently appointed, any false statement or failure to disclose medical information or criminal convictions will render me liable to disciplinary action which may include dismissal.

Signed ………………………………………………………………………. Date ……………………………………………………