Job Application Form CONFIDENTIAL Position applied for: (required) Lead Speech and Language TherapistOccupational TherapistQuality Assurance and Improvements OfficerSenior Support Worker - Connington CourtSupport Worker & Night Support Workers - Connington CourtSupport Worker & Night Support Worker - CrossbrookSupport Worker & Night Support Workers - Knoll HouseSupport Worker - Lucas HouseSupport Worker - Meridian CourtSupport Worker - Oakdene HouseSupport Worker – Park HouseSenior Support Worker – Somerford CourtSupport Worker & Night Support Workers - St. James HouseSupport Worker – Totteridge HouseSupport Worker & Night Support Worker - Willow CourtSupport Worker – Somerford Place PART 1 Surname (current family name): Title (Mr/Mrs/Miss/Ms/Other): Forename(s): Forename known as (if different): Previous surname (if applicable): National Insurance number: Are you aged 18 or over? (required for regulatory purposes): YesNo Current address: (required) Home telephone no: Work telephone no: Mobile telephone no: E-mail address: How did you hear about this position? (If a member of our staff team told you about us, please provide their name as we’d like to thank them for recommending us!) ELIGIBILITY TO WORK IN THE UK Are you free to remain and take up employment in the UK? YesNo Are you subject to immigration control? YesNo NB: If you are successful at interview, you will be required to present evidence of this prior to your appointment and may be subject to an Immigration Check. ABOUT YOU Please enter details of any professional membership (if applicable): Professional Body Name: Pin Number (if applicable): Expiry date: Do you hold a current driving licence? YesNo All staff with a clean driving license will be expected to take on the responsibility of driver if applicable. Are you a friend or relative of (or have other links with) a current/former employee or service user of the company? YesNo If yes, please provide their name and your relationship to them: Have you ever worked for the company? YesNo If yes, please complete the following: Your job title on leaving: Name of service: Dates employed (dd/mm/yyyy): CURRENT OR MOST RECENT EMPLOYER: Company name: Contact name: Working relationship: Company Address: Telephone no: Email: Job title: Date appointed (dd/mm/yyyy): Salary/rate of pay: Reason for leaving: Main duties: Available to take up employment with effect from (dd/mm/yyyy): PREVIOUS EMPLOYMENT RECORD AND REFERENCES Following interview, if you are short-listed, references will be taken from your current and most recent employer/s (a minimum of two references covering the past three years without any gaps as a combination or fully will be required). If you have never been in paid employment, academic or character references will be acceptable. Company name 1: Contact name: Working relationship: Company address: Telephone no: Email: Date appointed (dd/mm/yyyy): Date of leaving (dd/mm/yy): Job title on leaving: Reason for leaving: Company name 2: Contact name: Working relationship: Company address: Telephone no: Email: Date appointed (dd/mm/yyyy): Date of leaving (dd/mm/yy): Job title on leaving: Reason for leaving: Company name 3: Contact name: Working relationship: Company address: Telephone no: Email: Date appointed (dd/mm/yyyy): Date of leaving (dd/mm/yy): Job title on leaving: Reason for leaving: Company name 4: Contact name: Working relationship: Company address: Telephone no: Email: Date appointed (dd/mm/yyyy): Date of leaving (dd/mm/yy): Job title on leaving: Reason for leaving: CHARACTER REFEREE This must be someone who knows you personally for at least 3 years who is not a direct relative. Name: Address: Telephone no: Email: Relationship to you: Length of relationship: PART 2 QUALIFICATIONS Qualifications obtained from schools/colleges/universities including any relevant professional qualifications. NB: We will ask you to provide original copies of your degree/professional level or other relevant qualifications. Name & address of establishment 1: Dates (dd/mm/yy): Course title Qualifications received Name & address of establishment 2: Dates (dd/mm/yy): Course title Qualifications received Name & address of establishment 3: Dates (dd/mm/yy): Course title Qualifications received Name & address of establishment 4: Dates (dd/mm/yy): Course title Qualifications received Name & address of establishment 5: Dates (dd/mm/yy): Course title Qualifications received Name & address of establishment 6: Dates (dd/mm/yy): Course title Qualifications received RELEVANT TRAINING COURSES Please state any other relevant courses you have completed, including short courses. Course title 1: Date (dd/mm/yy): Course title 2: Date (dd/mm/yy): Course title 3: Date (dd/mm/yy): Course title 4: Date (dd/mm/yy): Course title 5: Date (dd/mm/yy): Course title 6: Date (dd/mm/yy): SUPPORTING STATEMENT Please use this section to support your application, providing evidence of your suitability for the post and how you meet the requirements of the job description. PART 3 CRIMINAL CONVICTIONS DECLARATION FORM Rehabilitation of Offenders Act 1974 The position for which you have applied is defined as eligible for a DBS check, taken from the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are 'protected' and are not subject to disclosure to employers, and cannot be taken into account. Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and Barring Service website. All candidates must complete the appropriate sections of this form. This section will be treated as confidential. It is emphasised that ex-offenders will only be assessed on their ability to do the job applied for, and any spent convictions and cautions will only be taken into account if relevant to the job. Are you a member of the disclosure and barring update service (DBS)?: YesNo Do you have any convictions, cautions, reprimands or final warnings that are not "protected" as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)? YesNo If yes, please supply details below. If no, please go straight to Part 4. Details of offence 1: Date (dd/mm/yy): Court: Sentence: Details of offence 1: Date (dd/mm/yy): Court: Sentence: Details of offence 2: Date (dd/mm/yy): Court: Sentence: Details of offence 3: Date (dd/mm/yy): Court: Sentence: Details of offence 4: Date (dd/mm/yy): Court: Sentence: PART 4 EQUAL OPPORTUNITIES This section is used for equality and diversity monitoring purposes only and will be detached from your application form. It will be treated as confidential by our Human Resources department and will not influence or determine whether you are short listed. The company is an equal opportunities employer and aims to ensure people are recruited, selected, trained and promoted on the basis of job requirements, skills, abilities and other objective criteria. The Company will ensure that no job applicant or employee receives less favourable treatment on the grounds of race, colour, nationality, ethnic or national origins, religious belief, sex, sexual orientation, marital status, disability, age or is disadvantaged by conditions or requirements which cannot be shown to be justified as being necessary for the safe and effective performance of the job. Sex: MaleFemale Date of Birth (dd/mm/yyyy): What is your ethnic group: White - English / Welsh / Scottish / Northern Irish / BritishWhite - IrishWhite - Gypsy or Irish TravellerWhite - Any other White background, please describe in box belowMixed / Multiple ethnic groups - White and Black CaribbeanMixed / Multiple ethnic groups - White and Black AfricanMixed / Multiple ethnic groups - White and AsianMixed / Multiple ethnic groups - Any other Mixed / Multiple ethnic background, please describe in box belowAsian / Asian British - IndianAsian / Asian British - PakistaniAsian / Asian British - BangladeshiAsian / Asian British - ChineseAsian / Asian British - Any other Asian background, please describe in box belowBlack / African / Caribbean / Black British - AfricanBlack / African / Caribbean / Black British - CaribbeanBlack / African / Caribbean / Black British - Any other Black / African / Caribbean background, please describe in box belowOther ethnic group - ArabOther ethnic group - Any other ethnic group, please describe in box below Additional ethnic group description (if appropriate): Do you consider yourself to have a disability?: YesNo We guarantee disabled applicants an interview, should they meet the minimum requirements of the job. The company will make any reasonable adjustments to enable attendance at an interview. Please indicate whether you are likely to require any of the following at any stage of your application: Please indicate whether you are likely to require any of the following at any stage of your application: No support requiredInformation in large printWheelchair accessSign language interpretingOther (please specify) in box below Additional assistance required at interview (if appropriate): DECLARATION I hereby declare that the information provided on this form is correct to the best of my knowledge. I also give my consent to have this information held and processed by the company in accordance with the Data Protection Act 1998. Name: Date (dd/mm/yy): Sequence Care Group take data protection very seriously. Your privacy is of the highest importance to us. In consideration of the General Data Protection Regulations, we would like to request your permission to store the details provided on this application form for recruitment purposes only. In order for us to continue to contact you we require your permission. Please select your preferred option: Please selectYesNo We may consider your application for opportunities that you may have not specifically applied for based on your skillset therefore, your details will be stored in a talent pool and contacted when a suitable position arises. The legal basis is our legitimate interests in finding an appropriate candidate for particular roles & vacancies. Do you consent to the above?: Please selectYesNo
