Jobs Staff Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Title *First Names *Surname *Email Address *Mobile Number *Date of Birth *Gender *— Select Choice —MaleFemaleNon-BinaryPrefer not to sayNational Insurance Number *Nationality *ReligionAddress (including postcode): *Emergency Contact: *Relationship to Applicant *Phone Number: *Address: *Do you currently have the legal right to work in the UK? *— Select Choice —YesNoPlease specify the type of right to work you hold in the UK:Full UK Driving Licence? *— Select Choice —YesNoDo you own transport? *— Select Choice —YesNoNMC PINSchool Name *School Dates (From – To) *School Qualifications: *School 2 NameSchool Dates (From – To)School Qualifications:College/University Name: *College/University Dates (From – To): *College/University Qualifications: *College/University 2 Name:College/University Dates (From – To):College/University Qualifications: Qualifications: to Dates Additional Places of Study and Qualifications: *Employer Name & Address: *Position Held: *Dates (From – To): *Reason for Leaving: *Employer 2 Name & Address: *Position Held: *Reason for Leaving: *Employer 3 Name & Address: *Position Held: *Reason for Leaving: *Additional Employment Information *Explain any gaps: *Mandatory training done in the past 12 months: Fire SafetyHealth, Safety & WelfareInfection Prevention & ControlSafeguarding AdultsMental Capacity Act (MCA)Deprivation of Liberty Safeguards (DoLS)Medicines ManagementMoving & Handling (Manual Handling)Basic Life Support (BLS)Equality, Diversity & Human RightsInformation Governance (Data Protection / GDPR)Care certificate? *— Select Choice —YesNoNVQ? *— Select Choice —YesNoIf yes please state which level:Any other training or certifications: (name and date of completion)Languages (Language / Spoken / Reading & Writing): *Experience Areas Mental HealthLDChallenging BehaviourBrain InjuryElderly CareDementia CareHomecareLive-in CarePalliative CareHobbies / Interests: *What attracts you to this position?: *Do you have a DBS? *— Select Choice —YesNoIs it online? *— Select Choice —YesNoIf online please provide number:Consent to share info (UK Border Agency / CQC / Audit Teams): *— Select Choice —YesNoIf No, provide explanation: Any criminal convictions? *— Select Choice —YesNoIf yes, provide details:Opt out of 48-hour limit (Yes/No): *— Select Choice —YesNoDo you consider yourself to have a disability or health condition that may require workplace adjustments for you to perform the duties of the role? *— Select Choice —YesNoIf you have selected “Yes”, please provide details of any reasonable adjustments or support that you consider may be necessary to enable you to undertake the role effectively. Provision of this information is voluntary and will be used solely for the purpose of assessing and implementing appropriate workplace support. Reference 1 Name: *Most recent employerCompany Name: *Email Address: *Phone Number: *Address: *Reference 2 Name: *Company Name: *Email Address: *Phone Number: *Address: *I confirm all information is true: *— Select Choice —YesNoSubmit
