Job Application Form

Position applying for

How did you find out about the role:

Upload your CV*

Personal Details

Title

 Mr Mrs Ms Miss Dr

Surname:

Forename(s):

Date of Birth:

Nat. Insurance No:

Home Address:

Postcode:

Tel. No:

Mobile:

Email Address:

Martital Status:

Nationality:

Next of Kin

 Mr Mrs Ms Miss Dr

Surname:

Forename(s):

Home Address:

Postcode:

Home Tel. No:

Relationship:

Education:

School:

Qualifications:

College/University:

Qualifications:

Professional Education (Nursing Staff only):

College attended:

Qualifications:

PIN No:

Expiry date:

Employment History:

Name of Employer:

Job Title:

Responsibilities:

Start Date:

Finish Date:

Reason for Leaving:

Name of Employer:

Job Title:

Responsibilities:

Start Date:

Finish Date:

Reason for Leaving:

Name of Employer:

Job Title:

Responsibilities:

Start Date:

Finish Date:

Reason for Leaving:

Name of Employer:

Job Title:

Responsibilities:

Start Date:

Finish Date:

Reason for Leaving:

Continue if required:

The Criminal Justice and Court Services Act 2000, provision for the non-disclosure of criminal convictions do not apply to certain occupations. The position for which you are applying is included in the excepted type of employment under the above mentioned order. Therefore it is necessary to answer the question. Your answer should include any “spent convictions”. Failure to disclose a criminal offence could lead to your application being rejected or in dismissal, should it subsequently be discovered.

Have you ever been convicted of a criminal offence?

Please tick the relevant box.*

 Yes No

If yes, please give details of dates*

References

Please note here the names, addresses and telephone numbers of 2 persons from whom we may obtain both character and work experience references.

Your present/previous employer must be included. (Not family members)

Position One

Position Held

Contact Name

Name and full address of Employer, School or University

Tel. No:

Email Address:

May we contact them prior to interview:

 Yes No

Position Two

Position Held

Contact Name

Name and full address of Employer, School or University

Tel. No:

Email Address:

May we contact them prior to interview:

 Yes No

Have you ever been disciplined at work or had your employment terminated following disciplinary proceedings?

Please tick the relevant box.

 Yes No

If yes, please give details:

Health:

Have you ever suffered a neck injury?

 Yes No

If yes, please give details:

Have you ever suffered a back injury?

 Yes No

If yes, please give details:

Do you suffer from Dermatitis?

 Yes No

If yes, please give details:

Do you feel you have a medical condition which will interfere with your duties in the post you are applying for?

If yes, please give details:

 Yes No

Have you been immunised against Hepatitis B?

 Yes No

Have you been immunised against Tuberculosis?

 Yes No

Name of GP.

Address

Tel. No:

How many times have you been off work due to ill health in the last twelve months and for how many days?

 

Declaration:

I confirm that the information I have given on this form is correct and complete, and that misleading statements may be sufficient for cancelling any agreement made. Because of the sensitive nature of the duties that the post holder will be expected to undertake, I also understand that the declaration will include details of any criminal convictions, cautions, reprimands and final warnings and any other information that may have a bearing on my suitability for the post. I understand too, that an Enhanced Disclosure will be sought in the event of a successful application.

 I agree I do not agree

Finding Turfcote

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T. 01706 229 735
E. info@TurfcoteCareHome.co.uk

Turfcote Care & Nursing Home, Helmshore
Road, Haslingden, Rossendale, BB4 4DP
Office Hours: 8:00am – 8:00pm.
Visiting Hours: 8:00am – 8:00pm.