1. Application Details
Position Applied For
Where did you see this?
Post advertised?
2. Personal Details
Please complete in block letters where possible.
Surname
First Names
Address
Post Code
Email Address
Telephone (Work)
Mobile Number
Full Driving Licence
Choose an option
Yes
No
Car Available
Choose an option
Yes
No
Date of Birth
National Insurance No.
Previous / other names
Place of Birth
Height
Previous address (if less than 5 years)
Previous postcode
As from (date)
3. Employment History
Most recent job first. Please use extra sheet if necessary.
3. Education & Qualifications
Please use extra sheet if necessary.
4. Other Information
Why do you think your previous experience, whether at work or otherwise, is relevant to this job?
5. Next of Kin Details
Name
Relationship
Mobile Number
Email Address
6. Reason for Leaving Last Employment
7. Medical History
Please give details of any disabilities, serious illnesses suffered in the past 2 years, days lost from work, hospitalisation, etc.
Do you have a disability you wish to tell us about? If so, are you registered disabled at a Job Centre?
9. Availability
Available to start work
Number of hours available
Willing to work weekends?
Select
Yes
No
10. Equal Opportunities
This information is treated in the strictest confidence.
Sex
Select
Female
Male
Other
I would describe myself as
Select
Black (African)
Black (British)
Black (Afro Caribbean)
Black (Asian)
White (British/European)
Cypriot (Greek)
Cypriot (Turkish)
Other
If Other, please specify
11. Disclosure of Criminal Background
Due to the nature of your appointment as Care Assistant/Domestic Assistant, Clare Home Care Ltd must enquire into the character and background of all staff.
Have you any convictions, bind-over orders, cautions or pending prosecutions?
Select
Yes
No
If yes, please give details
I give my permission for a DBS check to be made
Select
Yes
No
Signature (Type full name)
Date
12. Office Use Only
Application form sent
Application form returned
Invited to interview
Request references
References received
Rejection
Offer made
Start date
Induction pack
Training
Uniform/Tabard
Select
Yes
No
ID photo
Send Application
