Care Assistant Application Form

Contact Details
Title:
Forename(s):
Surname:
Telephone no.:
N.I. no:
Mobile no.:
E-mail address:
If you had a different surname at birth, or have ever had another surname or forename, you must provide details:
Any other name you
have been known by:
Name used from (date): Day/Month/Year eg. 01/01/2009
to (date): Day/Month/Year eg. 01/01/2009
Any other name you
have been known by:
Name used from (date): Day/Month/Year eg. 01/01/2009
to (date): Day/Month/Year eg. 01/01/2009
Current Address:
Post Code:
Country:
A complete five year address history must be supplied, please give details and dates. No gaps or omissions are allowed.
Address:
Post Code:
Country:
I lived at this address from: Day/Month/Year eg. 01/01/2009
to: Day/Month/Year eg. 01/01/2009
Address:
Post Code:
Country:
I lived at this address from: Day/Month/Year eg. 01/01/2009
to: Day/Month/Year eg. 01/01/2009
Click here to add another address
Were you born in the U.K? Yes No
If not, please specify:  
Birth place (town or city):
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?
Where did you hear about us?
Please be specific:
I am applying for:  
Full-time Part-time Weekends Nights 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:
     
     
     
     
   
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:
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 U.K. driving licence? Yes No
Do you drive a car? 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
Passport nationality:
Passport number:
Expiry date: Day/Month/Year eg. 01/01/2009
Place of issue:
Date of issue: Day/Month/Year eg. 01/01/2009
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:  
Are you registered under the Disabled Act? 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 giving false information will disqualify me from being employed by Clarendon Home Care Limited.
Name:
(you will be required to sign here if your application is taken forward)

Medical Details
Please answer all of the questions below. This section will be separated from your application on receipt and securely stored. This information will not be used in the recruitment process.
Have you ever suffered from any of the following:   Yes   No   If yes, please give additional information:
Chest pain, heart condition or high or low blood pressure?      
Epilepsy, fits, attacks of dizziness, blackouts fainting or migraine?      
Depression, mental illness or nervous breakdown?      
Diabetes, allergies or eczema?      
Tuberculosis, asthma or bronchitis?      
Shingles or chickenpox?      
Ulcers, irritable bowel syndrome kidney or urinary conditions?      
Any other current or recent medical condition or treatment which may affect your attendance or performance at work?      
Have you ever had an illness, condition or surgical operation that has prevented you from attending work for more than a week in the last twelve months?      
Any physical disabilities including sight and hearing defects?      
Please give details of any ongoing medication you are taking:
Name of your doctor:
Address:
Postcode:
Telephone no.:
  

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