Home Care Assistant Application Form

Contact Details
Title:
Forename(s):
Surname:
Telephone no.:
Mobile no.:
E-mail address:
Unsuccessful candidates will be informed by email only, postal address will not be replied to.
Current Address:
Post Code:
Country:

Emergency contact 1

  
Name:
Telephone no.:
Mobile no.:
Address:
Relationship:

Emergency contact 2

  
Name:
Telephone no.:
Mobile no.:
Address:
Relationship:
When could you start work?
Are you available to work weekends? We ask that all of our Home Care Assistants make themselves available for work at least one weekend in every two. Yes No
Where did you hear about us?
Please be specific:
I am applying for:  
Full-time Part-time Weekends Live-in Evenings
Are there any days you would prefer not to work?
Monday Tuesday Wednesday
Thursday Friday Saturday Sunday

Work History and Education
Please give details of any further education, and any qualifications gained.
Name and address of college:   Date from:   Date to:   Qualifications gained:
  Day/Month/
Year eg. 01/01/2009		   Day/Month/
Year eg. 01/01/2009		  
     
     
     
Name and address of school:   Date from:   Date to:   Qualifications gained:
     
     
     
     
   
Please provide a full work history since leaving secondary education. Details of any gaps in your employment history (e.g. while having a family or unemployed) must be fully explained. This is a requirement for this position, and an incomplete work history will leave us unable to employ you.
Name and address of employer:   Position:   Date from:   Date to:   Salary on leaving:   Reason for leaving:
         
         
         
         
         
         
Please tick the appropriate boxes to enable us to assess your experience.
Do you have experience assisting others with:
Personal care
Dressing or undressing
Taking medication
Eating
Housework
Do you have experience with:
People who have Multiple Sclerosis
People who are mentally ill
People who suffer from dementia
Support working
Please let us know of any skills or experience you have that you think would help you in this post:
Please give the name and address of two people from whom we can obtain a reference.
Please note that one reference needs to be from the manager of your last or present employer, at a business address.

Work Reference

  
Name:
Company:
Position:
Address:
Postcode:
Telephone no.:
Fax no.:
Email:
How long have you known this person and in what capacity?

Personal Reference

  
Name:
Address:
Postcode:
Telephone no.:
Fax no.:
Email:
How long have you known this person and in what capacity?
Have you ever been convicted of a criminal offence? Yes No
If yes, please give full details:
Have you ever been cautioned or issued with a formal warning regarding any criminal offence? Yes No
If yes, please give full details:
An enhanced CRB check will be done so please list any offences even if these are reprimands or offences prior to the age of eighteen years old. If your application is taken forward you will be required to sign this form to certify that the information you have given is true and complete.
Do you hold a current full UK or EU driving licence? Yes No
Do you have a car or have permanent access to a car for work purposes? Yes No
Do you require a work permit to take employment in the UK? Yes No
If the answer to the above question is yes, please answer the following questions. Otherwise go to the Declaration.
Do you hold a current work permit? Yes No
You have an automatic right to work if you are a citizen of the U.K., European Union and E.E.A and certain Commonwealth countries.
Do you need permission to work in the U.K.? Yes No
  If yes, please answer questions below.
Are you visiting the U.K. on a working holiday? Yes No
Do you require a work permit? Yes No
Do you hold a student Visa? Yes No
On entering Britain, what entry was placed on your passport by immigration? (Please give full details).
Have you recently been resident outside the U.K.? Yes No
If yes please give full details:  

Declaration
The information I have given in this application form is, to the best of my knowledge, complete and accurate in all respects.
I understand that to knowingly give false information will disqualify me from being employed by Clarendon Home Care.
I understand that to legally work for Clarendon Home Care, I will need a C.R.B. check certificate which remains my property and agree to pay the costs of the C.R.B. check if I am offered employment.
Name:
(you will be required to sign here if your application is taken forward)
  

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