Please Attach 3 Passport Photographs of yourself here. ilherf*rcffi. )1*eAthcnrr, Application Form

Transcription

1 Please Attach 3 Passport Photographs of yourself here ilherf*rcffi )1*eAthcrr, Applicatio Form

2 Your Details Title Foreames Surame Previous ames D.O.B. Address Home umber Mobile umber Other umber Nlumber JobTitle Documetatio checklist: T tr tr Photo ldetificatio (e.g. Passport, Drivig Licece) lf applicable - valid documetatio to prove your eligibility to work i UK (for example: work permit, Visa, Home office letter or documetatio) Proof of your address (for example: a bak statemet, utility bill) Proof of Natioal lsurace (Nl Card or Payslip) RelevatTraiig Certificates (for example Maual Hadlig) 3xPassportPhotographs Have you Read / Siged / ComPleted?: D Cotract for services 4SHourOptout CRB form - icludig 5 years history of addresses This applicatio form Next of Ki (Perso to be cotacted i a emergecy) Name RelatioshiP Cotact Number

3 O applicatio you will be requested to complete a CRB disclosure. Should ay applicat have a crimial record this will i o way obstruct youl registratio We are a equality ad diversity employer, ad therefore should you require ay assistace or alterative access to our offices we will be more tha happy to oblige. Employmet ad Experiece Most recet first (ad icludig ay gaps for study or uemploymet) From To Name ad oddress of employer J ob titl e ad dai ly duti es/ repo sibi I ities Employmet ad Experiece Cotiued Cliet Group/Category Yes No Job title Years/Moths Childre Learig Difficulties Adolescets Physically Disabled MetalHealth Elderly Substace Abuse Sesory lmpairmet Homeless Auxiliary/Hospital Worker Other

4 Traiig CourseTitle CompletedYES INO Date completed Maual / People Hadlig lfectio Cotrol Basic Life Support 1 CPR Food Hygiee Health ad Safety (lcludig Fire Safety) Epilepsy Awareess Abuse Awareess (POVA) Maagemet of Violece ad Aggressio I Medicatio'(speciff type) \ RestraitTra{ig (was kow as C & R) NVQ2/3/4 (please specify level) Other Other lf you do ot have a NVQ 2, are you willig to study towards oe? Educatio From To Name of School College / U iversity Qualificatios Other Preferred geographica I area Positio applyig for Do you have regular use of a vehicle How did you hear of Wilberforce Healthcare?

5 Persoal Health Questioaire Please aswer as to whether you have or are sufferig from the followig: Back trouble Stomach problems High blood pressure Diabetes Eye trouble of deafess Muscle joit trouble Recurrig chest disease Faitig attack yes / NO Asthma Fits or blackouts yes / NO Recurrig headaches YES/NO Metal illess Ear, ose, throat troubles Ski trouble yes / NO Have you ay disabilities affectig: (please highlight if YES) Stadig, walkig, stair climbig, liftig, use of hads, use of ladders, drivig. lthelast 2yearshaveyoubeeoffworkforayparticularilless? i lf YES. how mav davs did vou lose? trs/no Are you at preset havig ay treatmets prescribed via your Doctor? ' Are you a smoker? loculatios Type YES/NO If YES, please give the date of ioculatio Rubella Tetaus Hep B Polio Tuberculosis Varicella YEs/ NO I certiry that I am i good physical ad metal health. I declare that the above iformatio is true ad correct to the best of my kowledge ad that I have ot omitted relevat details. I agree to iform my agecy of ay chages i my health ad uderstad that if false statemets are kowigly made, it will result i de-registratio from the agecy. Siged Date

6 Refereces Names give should be from you last 3 employers (or at least Seiors with whom you worked). Refereces will be requested immediately uless otherwise stated.. False refereces will ot be accepted ad may result i refusal of your applicatio.. Frieds ad family members are u-acceptable referees.. Addresses ad cotact details must be a work place Name Name Name Title Title Title Work Address Work Address Work Address Tel: Tel: Tel: Fax: Fax: Fax: I declare that all the iformatio I have provided i this applicatio is correct ad to the best of my kowledge. I uderstad that should ay iformatio be foud to be icorrect, the my registratio with the agecy may be termiated without otice. I also cofirm that my referees are legitimate ad give Wilberforce Healthcare permissio to cotact ay of my previous employers. Siged Date

7 Protectio of Childre ad Vulerable adults Disclosure of Crimial Backgroud AtL APPLICATPNS MUST ANSWER ALL QUESTIONS OF THIS FORM The positio you are applyig for is exempt from the provisios of sectio 4(2) of the Rehabilitatio of Offeders Act1974 (exemptios) (amedmets) Order Applicats therefore caot withhold iformatio about covictios, which for other purposes are cosidered 'spet' uder the provisios of the Act ad i the evet of employmet. Failure to disclose ay covictios will result i the immediate removalfrom our register. A CRB Disclosure will be requested i the evet of your applicatio beig successful, if a applicatio holds a crimial record, this will ot prevet you from obtaiig a positio with Wilberforce Healthcare. Do you give coset for the cotets of your CRB Disclosure to be shared with potetial cliets o the behalf of Wilberforce Healthcare? Have you ever had discipliary actio take agaist you? Have you ever bee covicted of a crimial offece? lf YES, please cotiue o separate sheet. Mr/ Mrs / Miss / Ms FullName Address I have lived at this address sice What is your approximate height? What is your eye colour? Do you have ay idetifoig particulars? YEs / NO All iformatio you give will be strictly coftdetial. I believe all the iformatio above to be truthful, correct ad to the best of my kowledge. Prit ame Sigature Date-

8 Protectio of Childre ad Vulerable adults Disclosure of Crimial Backgroud ALt APPLTCATTONS MUST AI{SWER AtL QUESTIOI{S OF THIS FORM The positio you are applyig for is exempt from the provisios of sectio 4(2) of the Rehabilitatio of Offeders Act1974 (exemptios) (amedmets) Order Applicats therefore caot withhold iformatio about covictios, which for other purposes are cosidered 'spet' uder the provisios of the Act ad i the evet of employmet. Failure to disclose ay covictios will result i the immediate removalfrom our register. A CRB Disclosure will be requested i the evet of your applicatio beig successful, if a applicatio holds a crimial record, this will ot prevet you from obtaiig a positio with Wilberforce Healthcare. Do you give coset for the cotets of your CRB Disclosure to be shared with potetial cliets o the behalf of Wilberforce Healthcare? Have you ever had discipliary actio take agaist you? Have you ever bee covicted of a crimial offece? lf YES, please cotiue o separate sheet. Mr/ Mrs / Miss / Ms FullName Address I have lived at this address sice What is your approximate height? What is your eye colour? Do you have ay idetiffig particulars? All iformatio you give will be strictly cofldetial. I believe all the iformatio above to be truthful, correct ad to the best of my kowledge. Prit ame Sigature