Dbl Care Hampshire Ltd

DBL CARE HAMPSHIRE LTD

APPLICATION FORM FOR EMPLOYMENT

PERSONAL DETAILS

Position applied for: ______

First name: ______Title: Mr/Mrs/Miss/Mr/Others: ______

Middle names: ______

Surname: ______

Date of Birth (DD/MM/YYY: ______

National Insurance Number: ______

Place of Birth: ______

Current Home Address: ______

______

______

Postcode: ______

Telephone (Mobile): ______(Home): ______

Next of Kin: ______

Address if different from the one above: ______

______

______

Postcode: ______Telephone: ______

Do you hold a current driving licence / Yes / No / Driving licence Number:
Do you have your own transport / Yes / No

EDUCATION AND QUALIFICATIONS:

Name and Place of Education / Date / Qualifications attained and Grades
From / To

Please indicate if you have any of the following job related qualifications

1.  NVQ
If yes what Level: / Yes / No
2.  Basic Life Support
(First Aid) / Yes / No
3.  Moving and Handling / Yes / No
4.  Health and Safety / Yes / No
5.  Dignity and Respect / Yes / No
6.  Food Hygiene / Yes / No
7.  Safeguarding Of Vulnerable Adults / Yes / No
8.  Challenging Behaviour / Yes / No
9.  Infection Control / Yes / No
10.  Fire Training / Yes / No
11.  Safe Administration of Medicines / Yes / No
12.  Diversity and Equality / Yes / No
13.  Any Other (Specify): ______Date: ______

EMPLOYMENT HISTORY

Please put your most recent employer first and include any self-employment:

1.  Job Title: ______From: ______To: ______

Name and Address of Employer: ______

______

______

______Telephone: ______

Reason for Leaving: ______

______

2.  Job Title: ______From: ______To: ______

Name and Address of Employer: ______

______

______

______Telephone: ______

Reason for leaving: ______

______

3.  Job Title: ______From: ______To: ______

Name and Address of Employer: ______

______

______

______Telephone: ______

Reason for leaving: ______

______

HEALTH DECLARATION

Please give a brief explanation if you answer yes to any of these questions

Do you or have you suffered from any of the following conditions:

Mental or Nervous breakdown
/ Yes / No
Heart problems
/ Yes / No
Back trouble
/ Yes / No
Asthma
/ Yes / No
Physical disability
If YES RDP No ______/ Yes / No
Eye problems
/ Yes / No
Hearing problems
/ Yes / No
Allergies
/ Yes / No

Have had or having any of the following:

A major operation
/ Yes / No
Tuberculosis vaccination
/ Yes / No
Rubella vaccination / Yes / No
Hepatitis B vaccination / Yes / No

REFERENCES

Please give two references, one of which is your present/past employer. The other second one can be a character reference.

Name: ______
Address: ______
______
______
______
Postcode: ______
Telephone: ______/ Name: ______
Address: ______
______
______
______
Postcode: ______
Telephone: ______

GENERAL INFORMATION

We are required by law to ensure that anyone working for us is entitles to live and work in this country.

Are you legally entitled to work in the UK / Yes / No

PLEASE specify your Immigration status ______

In line with the Asylum and Immigration Act 1996 we have to ask for proof of your right to work in the UK. Therefore if you are invited for interview please bring with you the original copies of the following:

§  Evidence of NI number and name e.g. NI Card, an old payslip

§  A passport, an endorsement in a passport, birth certificate, or a letter from home office

For our internal office use purposes please answer the following question:

How did you find out about this DBL CARE LTD agency

Job Centre / Internet Search / Local Newspaper
Family or friends / Other / Recommendation

If recommended by who:………………………………………………

DECLARATION

Have you ever been convicted of any criminal offence

______

If YES PLEASE SPECIFY IN THE SPACE BELOW:

Because of the nature of the work applied for, this post is exempt from the provisions of section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants will therefore be required to undergo Enhanced Disclosure check provided by the Criminal Records Bureau (CRB). Any information provided will be strictly confidential, as will the results of the check.

I hereby declare that the information I have provided is accurate and all sections relevant to me have been completed honestly and to the best of my knowledge. I endeavour to inform

DBL CARE HAMPSHIRE LTD any changes, which would prevent me from undertaking the duties of the post, applied for.

Signed: ______Date: _____

DBL Care Limited, Registered Offices: 93 The Ridings, Hilsea, Portsmouth, PO2 0UF Registered in England: 10466946