Application Form

Carer Support Worker (Dementia)

1Personal Information

Surname First Name(s)

AddressDaytime Telephone Number:

Postcode:

Email address:

Are there restrictions on your ability to work in the UK? (Please give details)

REFERENCES

Please give details of two people (not relatives) who would be willing to provide references for you. Please note that one referee should be your present or most recent employer. Written references will be taken up after the offer of a position.

Name:...... Name ......

Occupation:...... Occupation:......

Address:...... Address:......

......

Telephone:...... Telephone:......

email address...... email address......

In what capacity you know this personIn what capacity you know this person

......

DECLARATION

The information above and in the rest of this application is to the best of my knowledge true and complete.

SignedDate

1Education

Full details of

Second Level Schoolfromtoexaminations and results

Full details of

College/Universityfromtocourses, awards and results

Other relevant training or professional qualifications:

2Current or Most Recent Employment

Name of present or most recent Employer:

Address:

Position & Salary:

Date employment commenced:Notice period:

Reason for leaving:

Please give brief description of your duties:

Please detail your key achievements in this post:

3Employment History

List below your past employment, beginning with your most recent, use a separate sheet if necessary Please make sure to account for any gaps

Name and address of employer:

From:To:Reason for leaving:

Your Job title:

Describe the work you did:

Name and address of employer:

From:To:Reason for leaving:

Your Job title:

Describe the work you did:

Name and address of employer:

From:To:Reason for leaving:

Your Job title:

Describe the work you did:

4Voluntary Experience

Please describe below any voluntary work you have participated in which is relevant to your application, using a separate sheet if necessary:

Please review the role description and person specification and take as much space as required to outline how your skills and experience meet the criteria outlined in those documents.

Carers Network

Equal Opportunities Monitoring Form

Information on this form will not be seen during the selection process

Name:

Job applied for:

How did you hear about this vacancy? (If in a newspaper, please specify which one)

How would you describe your ethnic origin?

White – British Asian – Bangladeshi

White – Irish Asian – Other

White – Gypsy / Irish Traveller Chinese

White – Other Mixed – White and Black Caribbean

Black – British Mixed – White and Black African

Black – Caribbean Mixed – White and Asian

Black – African Mixed – Other

Black – Other Arab

Asian – British Other Ethnic Group

Asian – Indian Prefer not to say

Asian – Pakistani

Please indicate your age group

Under 19 20-29 30-39 40-49 50+ Prefer not to say

Do you have aphysical or mental impairment which has a substantial and long-term adverse effect on your ability to carry out day-to-day activities?

Yes No Prefer not to say

Please indicate your gender

Male Female Prefer not to say

Office-use only

Short-listed interviewed offered-employment

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