Job Application Form - HIBA HOME CARE

Application Form

Post Applied for:

THE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED WITH CONFIDENTIALITY.

Section 1: Personal details

Last Name

First Name

Adress

Post Code

National Insurance

Home Telephone

Mobile Telephone

E-mail address

Are you eligible take up employment in the UK with no current immigration restrictions?

Yes No

Driving Licence – if relevant to post applied for. Do you hold a full, clean driving license valid in the UK?

Yes No

If you are successful you will be required to provide relevant evidence of the above details prior to your Appointment.
An enhanced DBS (Disclosure and Barring Service) check will be required for all positions

Section 2 Present or Most Recent Employment

(If now unemployed give details of last employer)

Job Title:

Period of Notice:

Date Joined:

Date Left (if applicable):

Employer Name:

Employer Address:

Main Duties:

Reasons for leaving (or reason for wanting to leave):

Section 3A Previous Employment

Previous Employment (most recent employer first). Please cover Full Job History from full time education to current employment (both paid and voluntary). References will be sought from previous employer and verification check may be made from previous employer that involved vulnerable adults and children to check the reason the employment ended.

From MM / YY

To MM / YY

FT or PT

Position Held

Employer (Name and Address)

Reason for Leaving

From MM / YY

To MM / YY

FT or PT

Position Held

Employer (Name and Address)

Reason for Leaving

From MM / YY

To MM / YY

FT or PT

Position Held

Employer (Name and Address)

Reason for Leaving

From MM / YY

To MM / YY

FT or PT

Position Held

Employer (Name and Address)

Reason for Leaving

Section 3B - Breaks in Employment History or between full time education

Please clearly explain any gaps in your Employment history (including month/year of gap):

Section 4 Education / Qualifications

Previous Education (start with most recent first). Please give details of Secondary, Further and Higher Education qualification achieved.

From MM/YY

To MM/YY

FT or PT:

Name and Location School/ College/ University

Subject and Qualification

Grades

From MM/YY

To MM/YY

FT or PT:

Name and Location School/ College/ University

Subject and Qualification

Grades

From MM/YY

To MM/YY

FT or PT:

Name and Location School/ College/ University

Subject and Qualification

Grades

Section 5 Training or Professional Qualifications

Please give details of any training and development courses or non-qualifications course which support your application. Start with most recent

Date

Awarding Body

Course Title & Details

Valid Until

Current Reference 1

Reference 2

Name:

Position:

Work Relationship:

Organisation:

Address:

Postcode

Telephone No:

E-mail:

Are you willing for this referee to be approached prior to the interview?

Yes No

Are you willing for this referee to be approached prior to the interview?

Yes No

Section 7 Right to Work

Citizens of the U.K., European Union and E.E.A. and certain Commonwealth citizens have an automatic right to work in the U.K. To establish whether this applies to you, please answer the following questions:

Please tick this box if you hold a Full U.K passport and provide details below If you do not hold a full U.K passport, please answer the following questions:

Do you need permission to work in the UK?

Yes No

Are you entitled to Indefinite Stay or Leave to Remain?

Yes No

Do you hold a Student Visa?

Yes No

Do you require a Work Permit?

Yes No

If yes, please give Passport Details / Dates of Document:

Section 8 Rehabilitation of Offenders Act (1974)

Professional Healthcare Solutions is committed to safeguarding and promoting the welfare of children and adults and expect all staff to share this commitment. All posts involving direct contact with vulnerable children and adults are exempt from the Rehabilitation of Offenders act 1974 (exemptions) Order 1975. The amendment to the Exemptions Order 1975 (2013) provides that certain spent convictions and cautions are ‘protected’ These are not subject to disclosure to employers and cannot be taken into account; guidelines are found on Disclosure and Barring Service website.

Do you have any convictions that are unspent under the rehabilitation of offenders’ act 1974?

Yes No

Have you ever been the subject of a formal caution

Yes No

Are you subject to any current outstanding disciplinary action or legal proceedings?

Yes No

Are you aware of any police enquiries undertaken following allegations made against you that may affect your suitability for the position?

Yes No

Have you been a resident in the UK from the last 5 years or more (as at today’s date)?

Yes No

Have you lived or worked abroad for any periods in excess of 3 months in the last 5 years?

Yes No

If yes, please give details / dates of offence(s) and sentence:

Section 9 Disability Discrimination Act

This Act protects people with disabilities from unlawful discrimination. We actively encourage applications from people with disabilities. The Disability Discrimination Act defines a disabled person as someone who has a physical or mental impairment which has a substantial and adverse long-term effect on his or her ability to carry out normal day to day activities.

Do you have a disability which is relevant to your application?

Yes No

If yes, please give details:

We will try to provide access, equipment or other practical support to ensure that people with disabilities can compete on equal terms with non-disabled people.

Do we need to make any specific arrangements in order for you to attend the interview?

Yes No

If yes, please give details:

Section 10 Data Protection

The information or data which you have supplied on this form will be processed and held on computer and hard copy. It will also be processed and held on your personal records if you are appointed to work with Vulnerable individuals. The data may be processed and shared with Professional Healthcare Solutions’ clients for the purposes of equality monitoring, compiling statistics, and for the keeping of other employment records. When you sign and return this form, you are giving us permission to process and hold on computer, the information or data you have supplied or referred to on it, including any information that you may consider to be sensitive and personal. By signing you are agreeing that, the information held on file maybe shared with relevant Inspectors, Authorities and Clients for auditing and verification.

We would therefore be grateful if you would complete and sign the declaration below. If you have any concerns about this or want to discuss it further, please contact our branch manager.

I (Print Name) …………………………………………… consent for access to information held on my personal file for inspection purposes.

Signed: …………………………………………………Dated: ………………………………………

Section 11 Declaration

Statement to be Signed by the Applicant

Please complete the following declaration and sign it in the appropriate place below. If this declaration is not completed and signed, your application will not be considered.

I understand that any offer of employment is subject to:
• references which are satisfactory to Professional Healthcare Solutions,
• a satisfactory Enhanced Disclosure & Barring Service (DBS) check,
• the entries on this form proving to be complete and accurate,

I hereby certify that:

Please attach professional certification and training documents below.

Full Name

Date:

Thank you for your interest in registering with Professional Healthcare Solutions, you will asked to sign your application at interview. If you would like to know if we have received your application form, please contact us on 0333 006 7844.

Please tick to confirm you agree to Professional Healthcare Solutions’ Terms Conditions and Privacy Notice.