Application Form -

APPLICATION FORM

Job Applied For:

Title

None Mr Mrs Ms

Surname

First Name

UK National Insurance No

Address

Postcode

Country

Mobile Telephone

Home Telephone

Work Telephone

Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National?

Yes No

If "no", do you have any evidence of entitlement to enter and work permanently in the United Kingdom, i.e. settled status?

Yes No

Upload your settlement evidence

If you have a disability, do you require any specific arrangements to enable you to attend interview

If yes, supply details

EDUCATIONAL & PROFESSIONAL QUALIFICATION

Please indicate subjects currently being studied

1. Subject/Qualification

Place of Study

Grade/Result

Year

2. Subject/Qualification

Place of Study

Grade/Result

Year

3. Subject/Qualification

Place of Study

Grade/Result

Year

4. Subject/Qualification

Place of Study

Grade/Result

Year

5. Subject/Qualification

Place of Study

Grade/Result

Year

6. Subject/Qualification

Place of Study

Grade/Result

Year

TRAINING COURSES ATTENDED

1. Course Title

Training Provider

Duration

Date Completed

2. Course Title

Training Provider

Duration

Date Completed

3. Course Title

Training Provider

Duration

Date Completed

4. Course Title

Training Provider

Duration

Date Completed

5. Course Title

Training Provider

Duration

Date Completed

6. Course Title

Training Provider

Duration

Date Completed

7. Course Title

Training Provider

Duration

Date Completed

8. Course Title

Training Provider

Duration

Date Completed

9. Course Title

Training Provider

Duration

Date Completed

10. Course Title

Training Provider

Duration

Date Completed

EMPLOYMENT HISTORY CURRENT OR MOST RECENT EMPLOYER

Employer Name

Address

Type of Business

Telephone

Job Title

Start Date

End Date

Grade

Salary

Reporting to

Notice Period

Reason for leaving

Description of your duties and responsibilities

PREVIOUS EMPLOYMENT
Please record below the details of your employment beginning with the most recent first. Please explain any gaps in employment in the 'Supporting Information' section.

1. Employer Name

Address

Job Title

Grade

From Date

To Date

Reason for leaving

Description of your duties and responsibilities

2. Employer Name

Address

Job Title

Grade

From Date

To Date

Reason for leaving

Description of your duties and responsibilities

3. Employer Name

Address

Job Title

Grade

From Date

To Date

Reason for leaving

Description of your duties and responsibilities

In this section, please give your reasons for applying for this post and additional information which shows how you match the person specification for the job. This can include relevant skills, knowledge, experience, voluntary activities and training etc

Additional Personal Information

Preferred Employment Type

The salary offered is negotiable depending on qualifications and experience. Please state the salary range acceptable to you.

Do you have a valid UK full driving licence

Do you have access to a vehicle which can be used for work purposes?

Please give the names of the people who have agreed to supply references. For all positions you must provide 2 references. If you are, or have been employed, these should be your two most recent employers. These may include your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. Please note that personal references such as friends and relatives are not acceptable. For all posts written references obtained must cover the preceding 3 years of employment. Satisfactory references are required to support our conditional offer of employment.

Referee 1

Surname/Family Name

First Name

Job Title

Address

Postcode

Country

Telephone

Fax

Relationship

Can the referee be contacted prior to interview?

Yes No

Referee 1

Surname/Family Name

First Name

Job Title

Address

Postcode

Country

Telephone

Fax

Relationship

Can the referee be contacted prior to interview?

Yes No

Where did you see this vacancy advertised?

MONITORING INFORMATION

Clear Choice Healthcare Ltd actively promotes the benefits of a workforce and are committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community.

Date of Birth

Gender

Male Female

DISABILITY DISCRIMINATION ACT 1995

The Disability Discrimination Act projects disabled people. This includes people with long-term health conditions. If you tell us that you have a disability, we can make reasonable adjustments to where you work and your work arrangements and at interview.

Do you consider yourself to have a disability

Yes No I do not wish to disclose this information

Please state the type of impairment which applies to you. People may experience more than one type of impairment; in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

REHABILITATION OF OFFENDERS ACT

The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions to employers after the rehabilitation period set by the Court has elapsed and the convictions become ‘spent’. However, this rule does not apply to specified professions, employments and occupations. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to: any employment or other work which is concerned with the provision of health services, and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to persons in receipt of such services in the course of his normal duties, or any employment or other work which is concerned with the provision of care services to vulnerable adults, and which is of such a kind as to enable the holder of that employment, or the person engaged in that work to have access to vulnerable adults in receipt of such services in the course of his/her normal duties One or both of the above apply to this post. You are therefore requested to provide details of all conviction, including those which would otherwise be considered as “spent”. All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected. Before you can be considered for appointment with Clear Choice Healthcare Ltd, we need to be satisfied about your character and suitably.

Have you any spent any spent or unspent criminal convictions or bindovers, or any cautions, warnings or reprimands?

Yes No

If yes, please give details

Your offer of employment will be subject to a satisfactory disclosure from the Disclosure and Barring Service. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment.

If you are related to a Partner or have a relationship with an employee of Clear Choice Healthcare Ltd, please state the relationship.

The information in this form is true and complete. I agree that any deliberate omissions, falsification or misrepresentation in the application form will be grounds for rejection or subsequent dismissal if employed by the organisation. This applies equally to any medical questionnaire/forms I may complete.

I agree to the above declaration

Name

Date