Application Form - Carers STRICTLY CONFIDENTIALApplication for Employment Please type or complete this form in black ink. You can either fill the form online or download it and send it via email to recruitment@divinehealthcaresolutions.co.uk. POST APPLIED FOR *DATE OF APPLICATION *PERSONAL DETAILSSurnameFirst Name(s) *Previous Name(s)Street Address *ZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweHome Telephone NoMobile No *Email Address *National Insurance No.Immigration DetailsPlease notify us of any dates you are available for interview *Are you a citizen of the EU? *Please select an optionYesNoDo you need a work permit? *Please select an optionYesNoCurrent driving license? *Please select an optionYesNoDo you have a car for work use? *Please select an optionYesNoNEXT OF KINSurnameFirst Name(s) *Relationship *Telephone No. *Street Address *ZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwePREVIOUS EMPLOYMENTA full employment history must be detailed beginning with your current employment and covering all reasons for gaps in any given year.Employment Details 1Employer’s Name *Position Held *Salary & Benefits *Reason For Leaving *From *To *Employment Details 2Employer’s Name *Position Held *Salary & Benefits *Reason For Leaving *From *To *Employment Details 3Employer’s NamePosition HeldSalary & BenefitsReason For LeavingFromToEmployment Details 4Employer’s NamePosition HeldSalary & BenefitsReason For LeavingFromToEmployment Details 5Employer’s NamePosition HeldSalary & BenefitsReason For LeavingFromToPREVIOUS EDUCATION(Original documents as proof of qualification will be required at interview)Secondary School / College / University *Examinations taken *Result *REHABILITATION OF OFFENDERS ACT 1974 – NOTICE TO OFFENDERSBecause of the nature of the work involved, the post for which you are applying is exempt from Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act (Exemption Order 1975). This means that you are not entitled to withhold information relating to any convictions you may have had.Do you have any convictions to disclose?YesNoAny information should be given on a separate sheet and sent with this application form. This information will be treated as confidential and will not necessarily preclude you from employment.Upload SignatureChoose FileNo file chosenDelete uploaded fileDate *Failure to declare or the falsification of any of the above details will result in the withdrawal of any job offer.ADDITIONAL PERSONAL DETAILSOutside interests, leisure time activities and other personal information which you think may assist us in evaluating your application.REFERENCESPlease give the name and address of at least two referees, one of whom must be your present employer or your most recent employer.Name & Status *Email AddressAddress *Tele[phone No. *This organization seeks to work in a flexible and family-friendly manner with its staff, however, unsocial hours are part and parcel of a quality care service. Weekend working is a requirement for all staff, the frequency of which will be determined at the interview.Please indicate holiday dates if already bookedPeriod of notice required in the present postEarliest start dateThank you for completing this application form.I declare that to the best of my knowledge, all of the information contained and documented herein is complete and truthful.Upload SignatureChoose FileNo file chosenDelete uploaded fileDate *FOR OFFICE USE ONLYApplicant shortlistedInterview DateReferences requestedVerbal reference checkDateAdditional Notes from ApplicationApplicant shortlistedFull employment history?Notes for interviewEqual Opportunities MonitoringThis section of the application will be detached and used for monitoring purposes only. Our organisation recognise and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation religion or belief. We welcome applications from all sections of the community.Date of BirthGenderMaleFemaleI do not wish to disclose thisRace Relations (Amendment) 2000I would describe my ethnic origin as (please indicate with a tickAsian or Asian BritishBangladeshiIndianPakistaniAny other Asian backgroundMixed RacedWhite & AsianWhite & Black AfricanWhite & Black CaribbeanAny other mixed backgroundBlack or Black BritishAfricanCaribbeanAny other Black backgroundWhiteBritishIrishAny other White backgroundOther Ethnic GroupChineseAny other ethnic groupI do not want to disclose thisEmployment Equality Regulations 2003Please select the option which best indicates your religion or describes your sexuality.Select Your SexualityLesbianGayBisexualHeterosexualI do not wish to disclose thisSelect Your ReligionAtheismBuddhismChristianityIslamJainismSikhismJudaismHinduismOtherI do not wish to disclose thisHealth Questionnaire(To be used for those applicants that have been deemed appointable).In order to comply with the Health and Social Care Act 2008 and the Equality Act 2010, please complete this questionnaire as fully as possible. Failure to do so could impede or delay your appointment. All information is confidential.Have you ever had or suffered from:Epilepsy/BlackoutsYesNoNervous Mental DisordersYesNoMigraine/HeadachesYesNoSensory ImpairmentYesNoSkin AllergiesYesNoBack pain/Previous Back InjuryYesNoHeart ConditionYesNoAsthmatic or respiratory ailmentsYesNoRecurring Incidence of IllnessYesNoAre you registered disabled?YesNoIf yes, please give detailsPlease List Below any Periods spent Outside of the United Kingdom as a Resident (do not include holidays)Please List below any vaccinations or immunisationsImmunization 1DateExpiryImmunization 2DateExpiryImmunization 3DateExpiryImmunization 4DateExpiryI declare that the information given is correct to the best of my knowledge. In my view, I am fit physically and mentally to undertake this post. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references.Upload SignatureChoose FileNo file chosenDelete uploaded fileDateDivine Healthcare Solutions Limited, 47 Field Road, Bloxwich, Walsall, West Midlands, United Kingdom, WS3 3JD,Phone: 03335770655Email: info@divinehealthcaresolutions.co.uk | Website: www.divinehealthcaresolutions.co.ukSubmit & Download