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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