Recruitment

Names

Title (required)

Surname (required)

Forename(s) (required)

Previous Surname (if any)

Commonly Known as (if any)

Address Information

Address (required)

Post Code (required)

Landline Tel No.

Mobile No..

Nat Ins No.

Date of Birth

Nationality

First Language

Country of Origin

No. and age of children

Religion

Do you own a car?
---YesNo

Do you hold a full UK driving license
---YesNo

Next of kin details

Name

Address

Post Code

Telephone

Relationship

Current / Most Recent Employer Information

Employer

Address

Post Code

Telephone

Email

Position Held

Date Appointed

Date Left

Present Salary

Reason for Leaving

Experience

Please print details of all your employment/schooling for a period of at least the last ten years starting with current employment and including any voluntary work.

The Company will need an explanation of any gaps in employment and a CRB Enhanced Disclosure will be requested in the event of an applicant being offered a position.

Please enter the following details for your previous employers:
From, To, Employers Name & Address, Job Title & Duties, Reason for Leaving

Education

Please list any courses attended, the dates and relevant qualifications gained.
(The inclusion of a separate CV would be helpful but not essential)

School Education

College / University Education

Employers Education and/or Training

Other Experience

Personal Statement

References

Please give the names and addresses of two referees who can provide information on your competence in a caring role. (One should be your present or last employer) We cannot accept a reference from a relative or friend.

Reference 1

Name 1

Position 1

Address 1

Contact Number 1

Fax Number 1

Email 1

In what capacity do you know this person? 1

Reference 2

Name 2

Position 2

Address 2

Contact Number 2

Fax Number 2

Email 2

In what capacity do you know this person? 2

Rehabilitation of Offenders Act 1974 &Theft Act 1968

By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendments) Order 1986, the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such a kind as to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties.

Because of the nature of our business you are required to submit to a Criminal Records Bureau check. The Registered Nursing Home Association will assist in the obtaining of your CRB check and they will ensure that any disclosures made by the CRB remain strictly confidential.

Have you ever been convicted in a Court of Law and/or cautioned in respect of any offence?
---YesNo

If yes, please give details

Availability for Working

Please specify your availability to work, you should tick all appropriate boxes.
Please note that your availability to work contributes towards our decision when offering employment and as such during your employment with us, if your availability does change from that listed below, your employment may be terminated on that basis if we are unable to accommodate your change of availability.

 Part time (up to 30hrs) Full time (30hrs plus) Early mornings (7am start) Evenings (4pm start) Evenings (6pm start) Nights (10pm - 6am) Weekends  Other work

If yes please give details:

When will you be able to start work?

Details of any upcoming holidays or events which may affect your start date

General Information

Are you a member of a union or professional organisation offering Indemnity insurance?
---YesNo

If yes enter name

Uniform Size

How did you first hear about this company?

Passport and Work permit details

for applications from overseas only

Work permit? ---YesNo

Expiry date

Passport Nationality

Place of Issue

Passport Number

Date of Issue

Expiry Date

Known Restrictions in use

Declaration

I hereby declare that the information provided on this form is complete and correct and any untrue or misleading information will give my employer the right to terminate any employment contract offered.

I agree that Diamond Home Care LTD reserves the right to require me to undergo a medical examination. (Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor).

Name (electronic signature, required)

Date (required)

Your Email (required)

Diamond Home Care is an Equal Opportunities employer and our staff are selected on merit irrespective of race, sex, disability, etc. In order to monitor the effectiveness of our Equal Opportunities Policy we would ask all applicants to provide the following information by indicating the broad ethnic group to which you belong.

Please tick the appropriate category
 White Bangladeshi Black African Indian Chinese Black Caribbean Pakistani Black African Other Other
If other please specify

Gender
 Male Female Other

Enter the following: