Form - Health Care First Choice Limited

Recruitment Form

APPLICATION FORM

First Name*
Surname*
Email*
Date of Birth*
MM slash DD slash YYYY
Nationality*
Ethnic Origin
Marital Status*
Gender*
Select one
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postcode*
Home number*
Mobile Number*
National Insurance Number*
What driving license do you hold?
Do you own a vehicle?*
- Yes
- No
Position*
- Community Care Worker
- Support Worker
Preffered Position type*
- Full Time
- Part Time
Preferred working hours
Please state which working hours you would prefer. (Listing any commitments which could restrict your working hours, please note that working alternate weekends is compulsory)
Where did you hear about this vacancy?
EDUCATION
Name of School
Qualifications from School*
Other Qualifications
Please give details of any experience and skills you have relating to the job of a care worker.
EMPLOYMENT HISTORY
Please list names of employers since leaving school, period of working with each employer and reason for leaving. Please start with your current/most recent employer and include the address.
Employer 1: Start Date, End Date, Reason for Leaving
Employer 2: Start Date, End Date, Reason for Leaving
Employer 3: Start Date, End Date, Reason for Leaving
Employer 4: Start Date, End Date, Reason for Leaving
Employer 5: Start Date, End Date, Reason for Leaving
Upload CV (Optional)
Max. file size: 256 MB.
References
Please give the names and addresses of two referee's from your current place of work, one must be your current manager. (Must be Employment references.)
Reference 1: Company, Contact Name, Telephone Number, and Capacity in which you know the referee
Reference 2: Company, Contact Name, Telephone Number, and Capacity in which you know the referee
CRIMINAL RECORD CERTIFICATES
If the position you are applying for (whether paid or voluntary is listed is schedule 1, Part 2 of the Rehabilitation of Offenders Act Order 1975, Healthcare 1st Choice is entitled to ask Exempted Questions as defined by Section 113(5) Of the Police Act 1997 about you. From July 2002 Healthcare 1st choice ltd is required by The Domiciliary Care Agencies Regulations 2001 to obtain a criminal record certificate in relation to any person who is a care manager or domiciliary care worker. This means that if your application is successful we will obtain from the Disclosure and Barring Service (formerly known as Criminal Records Bureau) a criminal record certificate relating to you, before your appointment is confirmed. You are, however encouraged to tell us about your criminal record before we obtain a criminal record certificate.
Do you have a prosecution pending or have you ever been convicted at a court, cautioned by the police for any offence or charged with a civil conviction?
If YES - Please provide details below of pending prosecutions, convictions, cautions, bind over orders or civil convictions, including approximate date, the offence and the court or police force which dealt with the offence
Declaration
I declare that I believe that the information I have given on the above application form is true.
Having a criminal record will not necessarily stop you working with us.
DECLARATION

This will depend on the nature of the position and the circumstances and background of your offences. Healthcare 1st choice Ltd. has a written policy on the recruitment of ex offenders and we will give you a copy of it on request. Healthcare 1st Choice Ltd. observes the "Code of Practice for Registered Persons and Other Recipients of Disclosure Information" published by the Disclosure and Barring Service (formerly known as Criminal Records Bureau) at https://www.gov.uk/government/organisations/disclosure-and-barring-service on behalf of the Home Office, and we will give you a copy of it on request.
Signed*
Date*
MM slash DD slash YYYY

Recruitment Form

APPLICATION FORM

EDUCATION

EMPLOYMENT HISTORY

References

CRIMINAL RECORD CERTIFICATES

CONTACT

QUICKLINKS

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