When Complete, Please Email This Application Form to Your Consultant by Email

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When complete, please email this application form to your consultant by email:

RECRUITMENT APPLICATION FORM

PERSONAL DETAILS

Surname:
All Previous Names: / Forename(s):
Role Applied for: / Date of Birth:
___/____/______
Address:
Post Code: / Email:
Daytime Tel No: Office use / Evening Tel No: Office use
Do you have a current Driving Licence:

Yes No / How long have you had your licence license?

2 years or less More than 2 years
Do you have any endorsements on your Driving License? Yes or No (If Yes please give details)

Yes No / Do you speak or read any other languages? Yes or No (If Yes please give details)
Yes No
Nationality: / National Insurance No:
Do you require a visa to work in the UK
Yes No / If yes, when does your visa expire?:

2. EDUCATION (Details below may be checked)

School/College/University / Examinations Passed/Qualifications gained
(what certificates can you supply?)

DBS/CRB CERTIFICATE (Up to Date)

Have you got an updated DBS/CRB Certificate? Yes: No:

Please write down other Qualifications/ Experience down below:

4. EMPLOYMENT DETAILS / HISTORY

Present and Most Employer
Type of Business: / Job Title:
Start Date:
___/___/_____ / Leaving Date:
___/___/______
Employer Address:
Post Code:
Duties/ Responsibility :
Salary/ Rate:______
Previous Employer
Type of Business: / Job Title:
Start Date:
___/___/_____ / Leaving Date:
___/___/______
Employer Address:
Post Code:
Duties/ Responsibility :
Salary/ Rate:______

5. EQUAL OPPORTUNITIES & ETHNIC MONITORING

Bluebirds Healthcare LTD wholeheartedly supports the principle of equal opportunities in employment and opposes all forms of unlawful or unfair discrimination on the grounds of sex, race, nationality, ethnic or national origin, marital status, age or disability.

Under the requirements of the Race Relations Act, the employer must monitor the numbers of staff in post and the numbers of applicants for employment, training, and promotion by reference to the ethnic groups to which they belong.

In order to comply with the Race Relations Act & to identify any barriers that may exist within our organisational procedures, we monitor the ethnic origin of all employees throughout the employment cycle by requesting the following information.

All information is confidential. This form will be separated from your application before consideration of candidates takes place and will not be available to those involved in the selection process.

Gender

Male Female
My Age Group:
16-19
20-25
25- 35
35 -45
45-60
Please Note: Minimum age legislation dictates that Care workers in general must be 16 years old or older.
What is your marital status:

Married Single
What is your Ethnic group?
WHITE MIXED ASIAN
British White and Black Caribbean Indian

Irish White and Black African Pakistani

Other White White and Asian Bangladeshi

Other Mixed Other Asian
BLACK OR BLACK BRITISH CHINESE OR OTHER ETHNIC GROUP
Caribbean Chinese
African
Other
ANY OTHER ETHNIC GROUP PLEASE SPECIFY......

6. PROFESSINAL REFEREES

(Please note you must use your most recent jobs/ or education institution. This must correspond with Section 4)

Current or most recent Employer (1) Previous employer (2)

Name: / Name:
Address:
Post Code: / Address:
Post code:
Email Address: / Email Address
Tel Number: / Tel Number:
Job title: / Job title:

Character reference – Not Member of your Family

(Please note that in this section you are required to name one character referee which can be anyone but not a family member)

Surname: Forename (s):
Address:
Post code:
Telephone:
Email
Relationship to you:

7. Please give details of your next of kin, who can be contacted in an emergency

Surname: / Forename (s):
Telephone: / Email:
Relationship: / Address:
Post code:

I give my consent to obtain references to support this application once an offer of employment has been made and accepted and release the Company and referees from any liability caused by giving and receiving information.

I confirm that the information given on this form is to the best of my knowledge true and complete. Any false statement may be sufficient cause for rejection or dismissal.

Signed: ______Date: ____/____/______

8. CRIMINAL RECORD

Workers of The Agencyare subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions. You will not be eligible for work in a Care setting if you are on the DBS Register(s).

Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.
SIGNATURE and DECLARATION – IMPORTANT – READ BEFORE SIGNING
I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.
I understand that I cannot be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS.
I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise the organisation to request a DBS Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred Care workers, or withdrawal of any registration required by my employment status.
Signed:______Date:____/____/______