Othencare

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Othen Care application form

Position applied for: Job Reference:
A: PERSONAL DETAILS
Title: if 'other' please state
Surname:	Forename(s):
Address: postcode:

Telephone:	Private	Business	Mobile

Date of Birth	Place of Birth	Nationality
email address:
B: HEALTH & DISABILITIES
Do you have any disabilities which may be relevant to this Job Application? Yes / No If 'yes' please describe them:

Are you Registered Disabled? Yes / No		RDP No:

Overall state of health:	Excellent / Good / Poor
Hearing:	Excellent / Good / Poor
Eyesight:	Excellent / Good / Poor
I wear:	Spectacles / Contact lenses / Neither
Have you had treatment for any condition relating to the abuse or misuse of drugs or alcohol within the last 5 years? Yes / No
Are you prepared to undergo a medical examination? Yes / No

C: DRIVING RECORD

Are you a car owner? Yes / No

Make: Model: Year:

Current Driving Licence: Provisional / Full / PSV / None

Driving Licence valid from: to:

Details of current endorsements:

Have you ever been disqualified from driving, or had insurance refused?
Yes / No

If 'yes' please provide brief details:

D: EDUCATION & PROFESSIONAL TRAINING (from year 11)
Education Centre (school, college etc)	DATES	Qualifications gained
1. Secondary Education (Secondary School)




2. Higher Education (University / College / Polytechnic)




3. Further Education (Professional Training)




4. Membership of Professional Organisation

E: LEISURE ACTIVITIES

Please provide brief details of your hobbies, sport and other leisure pastimes in which you participate:

Languages (other than English):
spoken / fluent / written / read
spoken / fluent / written / read

F: CRIMINAL RECORD CERTIFICATES

If the position you are applying for (whether paid or voluntary) is listed in Schedule 1, Part II of the Rehabillitation of Offenders Act (Exceptions) Order 1975, we are entitled to ask Exempted Questions as defined by Section 113(5) of The Police Act 1997 about you. From July 2002 we are required by The Domiciliary Care Agencies Regulations 2002 to acquire a Criminal Record Certificate in relation to any person who is a Care Manager or Domiciliary Care Worker. This means tha tif your application is successful we will obtain from the Criminal Records Bureau a Criminal Record Certificate relating to you before your appointment is confirmed.

Having a criminal record will not necessarily bar you from working with us. This will depend upon the nature of the position and the circumstances and background of your offences. We observe the "Code of Practice for Registered Persons and Other Recipients of Disclosure Information" published by the Criminal Records Bureau on behalf of the Home Office, and we will provide you with a copy of it upon request.

G: EMPLOYMENT HISTORY
Please provide details of all employment, beginning with your present or most recent job first.
DATES	Employer	Salary	Position(s) held	Reason for leaving

H: VOLUNTARY & COMMUNITY WORK EXPERIENCE
DATES	Organisation	Position(s) held	Reason for leaving

I: JOB FLEXIBILITY

Prepared to work: Full time / Part-time / Shifts

If Part-time please indicate preferred hours:

Details of any other work which you will continue to undertake if you are offered this Job Position:

Please provide details of any outstanding holidays to be taken:

Available to take up employment from:

J: REFERENCES
Please provide details of 2 referees who we may approach with regards to this Job Application. These referees must not be members of your family, and one must be your present or most recent employer:
Name:	Address:
Telephone number:	Occupation:
Name:	Address:
Telephone number:	Occupation:

K: DECLARATION BY JOB APPLICANT

ANY PERSON, UPON SUBSEQUENT EMPLOYMENT, THAT IS FOUND TO HAVE KNOWINGLY SUPPLIED FALSE OR MISLEADING INFORMATION, OR HAS DELIBERATELY WITHHELD RELEVANT INFORMATION, WILL BE SUMMARILY DISMISSED.

I have read and understood the information supplied to me in relation to this Job Position, and the information requested in this Job Application Form. I confirm that all information supplied by me is true and correct to the best of my beliefs.

I give the prospective employer the right to follow up all references and to make any other job-realted enquiries as may be deemed necessary.

WE ARE AN EQUAL OPPORTUNITIES EMPLOYER
The sole criterion for selection of applicants will be suitability for the Job Position, regardless of age, gender, gender orientation, background, culture, ethnic denomination, religious affiliation, marital status or disability. This is in accordance with our declared Equal Opportunities & Diversity Policy, No 205.

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