Application for Employment — Birkdale Village Care Home

Please complete this application form on your device. You can fill it in using any phone, tablet, or computer. When you reach the end, sign with your finger (on a touchscreen) or your mouse, then tap “Download Completed Form (PDF)”. Save the PDF and email it back to the manager. Fields marked * are required.

Note on the Health Questionnaire (Part 2): the health questionnaire is presented as a separate section to be completed after a conditional offer of employment has been made, in line with usual recruitment practice. If you are completing this form before a conditional offer, you may leave Part 2 blank and complete it later.

1 Position Applied For

Position applied for *

2 Personal Details

Title

Surname *

Forename(s) *

Address *

Post Code *

NI Number

Date of Birth *

Email *

Mobile Tel No *

Home Tel No

Work Tel No

Marital Status

Do you hold a current driving licence?

Yes No

Do you have any endorsements / penalty points? If so, give details:

Do you require a work permit to work in the UK?

Yes No

Are you applying under a government employment scheme? If so, please specify:

3 Education & Training

Secondary Education

Schools / colleges attended, dates, and qualifications attained.

Further Education

Colleges / universities attended, dates, and qualifications attained.

Other Relevant Training

Include organisation, dates and duration.

4 Present & Previous Employment

Present Employment (if applicable)

Job Title

Name & full address of employer

Brief description of duties

Tel No

Date appointed

Period of notice required

Previous Employment (starting with most recent)

5 Experience, Skills & Personal Statement

Please give details of your knowledge, skills and experience (including outside interests, voluntary work, and employment scheme attendance) which you feel relevant to this post.

6 Attendance Record

How many episodes of illness have you had during the past 2 years?

How many days in total have you been ill and unfit for work over the same 2-year period?

Any comment you wish to make about your health or attendance record:

7 Rehabilitation of Offenders Act 1974 & Disclosure

Applicants must refer to the guidance notes before completing this section. If the job you are applying for is regulated and exempt from the provisions of the Rehabilitation of Offenders Act 1974 (ROA), you must not withhold information about convictions which for other purposes are considered “spent” under the Act. Any information given will be treated in the strictest confidence and will only be considered in relation to applications for such posts. The home supports the rehabilitation of offenders and possession of a conviction will not necessarily mean unsuitability for employment in exempt posts. All convictions will be examined on an individual basis and given full and fair consideration. Offers of employment for the post applied for will be subject to receipt of a satisfactory Disclosure via the Disclosure and Barring Service.

Have you been convicted of any criminal offence?

Yes No

If yes, please give details of offence, including date and sentence:

8 Referees

Please give the name, address, email and telephone number of 2 referees. Referees should be your present and previous employers, wherever possible.

Referee 1

Name *

Position / relationship

Address

Telephone

Referee 2

Name *

Position / relationship

Address

Telephone

Do you have any objection to references being taken prior to interview?

Yes No

Are you related to any member of Birkdale Village Care Home? If so, please state to whom and the nature of the relationship.

9 Declaration

I declare that the information given on this form is to the best of my knowledge correct. I understand that canvassing, either directly or indirectly, any employee of the home or giving false information or misleading information may lead to disqualification and, if appointed, may lead to my dismissal. Furthermore, I understand that the information will only be used for recruitment and selection purposes and that it will only be kept on file by Birkdale Village Care Home, and if I am appointed to the post then the information that it contains will be used to form part of my personal file for employment purposes (except for disclosure information, which will only be kept for 6 months).

I confirm that I have read and agree with the declaration above. *

Signature * — sign below with your finger or mouse

✎ Sign here

Date: — (auto-filled when you sign)

A Health Declaration — Section A

Please complete this section and return it to the Home Manager. All information on this form will be treated as strictly confidential and will not be divulged to a third party without written consent. Advice given to a third party about health or fitness of individuals is given in general terms only. Please answer all the following questions. If the answer to a question is YES, please give details.

Full name

Have you ever had any of the following?

Condition	Yes	No	Details (if yes)

B Health Declaration — Section B

Question	Yes	No	Details (if yes)

How many days have you lost through sickness in the last year?

I know of no health reason that will affect my ability to undertake the duties of the post for which I am applying. All the answers on this form are true and correct to the best of my knowledge.

Signature — sign below with your finger or mouse

✎ Sign here

Date: — (auto-filled when you sign)

When you have finished, tap the button below to download your completed form as a PDF.
Save it to your device and email it back to the manager.