FORM ONE

    Job Reference Number:

    Job Position:

    A. PERSONAL DATA

    Title:

    Surname:

    Forenames:

    Email:

    Address:

    Mobile Number:

    Post Code:

    Do you need a permit to work in the UK?: YesNo

    NI Number:

    NMC Pin (Nurses Only):

    Pin Expiry Date:

    Do you have regular use of a car?: YesNo

    Languages (Spoken / Written / Read):

    B. NEXT OF KIN

    Full Name (Next of Kin):

    Relation to you:

    Telephone Number:

    Email:

    Address:

    Post Code:

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    FORM TWO

    D. EDUCATION & PROFESSIONAL TRAINING (from year 11)

    Secondary School Education:

    Qualification gained:

    From:

    To:

    Higher School Education (University / College / Polythechnic):

    Qualification gained:

    From:

    To:

    Further Education (Professional Training):

    Qualification gained:

    From:

    To:

    Membership of Professional Organisations::

    Qualification gained:

    From:

    To:

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    FORM THREE

    G. EMPLOYMENT HISTORY

    From:

    To:

    Employer:

    Position held:

    Salary:

    Reason for leaving:

    From:

    To:

    Employer:

    Position held:

    Salary:

    Reason for leaving:

    From:

    To:

    Employer:

    Position held:

    Salary:

    Reason for leaving:

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    FORM FOUR

    F. PERSONAL DBS CERTIFICATES

    If the position you are applying for (whether paid or voluntary) is listed in Schedule 1, Part II of the Rehabilitation of Offenders Act (Exceptions) Order 1975, we are entitled to ask Exempted Questions as defined by Section 113(5) of the Police Act 1997 about you. We are required to check a DBS Certificate in relation to any person who is a Care Manager or Care Worker. If your application is successful and before your appointment is confirmed, you will be required to submit a personal current and valid DBS Certificate for our inspection.

    Having a criminal record will not necessarily bar you from working with us. This will depend upon the nature of the position and the circumstances and background of your offences. We observe the “Code of Practice for Registered Persons and Other Recipients of Disclosure Information” published through the Disclosure & Barring Service on behalf of the Home Office, and we will provide you with a copy of it upon request.

    Your Initials:

    Date:

    I. JOB FLEXIBILITY

    Prepared to work: Full TimePart TimeShift

    If PART-TIME please indicate preferred hours:

    K. BANK DETAILS

    Account Name:

    Account Number:

    Sort Code:

    Name Of Bank:

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    FORM FIVE

    J. REFERENCES

    Please provide details of 2 referees who we may approach with regards to this Job Application. These referees must not be members of your family, and one must be your present or most recent employer:

    REFERENCE ONE:

    Full Name:

    Address:

    Telephone:

    Occupation:

    REFERENCE TWO:

    Full Name:

    Address:

    Telephone:

    Occupation:

    May we contact your referees prior to making a job offer?: YesNo

    L. DECLARATION BY JOB APPLICANT

    ANY PERSON, UPON SUBSEQUENT EMPLOYMENT, THAT IS FOUND TO HAVE KNOWINGLY SUPPLIED FALSE OR MISLEADING INFORMATION, OR HAS DELIBERATELY WITHHELD RELEVANT INFORMATION, MAY BE SUBJECT TO DISCIPLINARY PROCEEDINGS WHICH MAY RESULT IN DISMISSAL

    I have read and understood the information supplied to me in relation to this Job Position, and the information requested in this Job Application Form. I confirm that all information supplied by me is true and correct to the best of my beliefs.

    I give the prospective employer the right to follow up all references and to make any other job-related enquiries as may be deemed necessary.

    Your Initials:

    Date:

    SPEED CARE SERVICES LIMITED IS AN EQUAL OPPORTUNITIES EMPLOYER

    The sole criterion for selection of applicants will be suitability for the Job Position, regardless of gender, background, culture, ethnic denomination, religious affiliation, marital status or disability.

    Data Protection Act 1998: Your signature on this document gives us the right, under the Data Protection Act 1998 to process the information you have given, including data of a sensitive nature, relating to your application for employment. Any processing of the data by us will be in accordance with our Policy and the processing principles set out in the Act. Application forms of unsuccessful candidates will be destroyed after 6 months in accordance with our Record-keeping Policy.

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    FORM SIX

    DECLARATION OF HEALTH & MEDICAL FITNESS

    A. PERSONAL DETAILS

    Surname:

    Forenames:

    Date of Birth:

    Telephone:

    Address:

    GP Name & Address:

    Do you have, or have you ever suffered from, the following:

    Typhoid Fever/Paratyphoid Fever? Enteric Fever?:
    YesNo

    Details:

    Date:

    Salmonella Infection?:
    YesNo

    Details:

    Date:

    Diarrhoea/Vomiting for more than 2 days?:
    YesNo

    Details:

    Date:

    Frequent Infections of the Upper Respiratory Tract e.g. Colds, Sinusitis, Sore Throat, etc.?:
    YesNo

    Details:

    Date:

    Severe Chest conditions, such as chronic Bronchitis with Phlegm, Pleurisy, TB (Tuberculosis?): YesNo

    Details:

    Date:

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    FORM TWO

    Discharge from the Ear/ Eyes/ Nose? :
    YesNo

    Details:

    Date:

    Problems with the Heart and or Circulatory System, such as Angina, Abnormal Blood Pressure, Anaemia?:
    YesNo

    Details:

    Date:

    Problems with Sight or Hearing, such as Colour Blindness, Hard of Hearing?:
    YesNo

    Details:

    Date:

    Skin Rash / Eczema / Dermatitis / other Skin Disease?:
    YesNo

    Details:

    Date:

    Recurrent Boils / Styes / Septic Fingers?:
    YesNo

    Details:

    Date:

    Fits or Blackouts?:
    YesNo

    Details:

    Date:

    Migraines and other Severe Headaches?:
    YesNo

    Details:

    Date:

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    FORM THREE

    Mental Health problems, such as Stress, Hypertension, Addictions, Depression or Anxiety Attacks?:
    YesNo

    Details:

    Date:

    B. CONFIDENTIAL MEDICAL DECLARATION

    Have you been an in-patient or out-patient at a hospital within the last 5 years?:
    YesNo

    Details:

    Date:

    Have you had treatment for any condition relating to the abuse or misuse of alcohol or drugs within the last 5 years?:
    YesNo

    Details:

    Date:

    Do you regularly take any type of prescription medication?:
    YesNo

    Details:

    Date:

    Have you ever suffered from a back strain, slipped disc, or other conditions of the back, joints or ligaments?:
    YesNo

    Details:

    Date:

    Are you registered disabled?:
    YesNo

    Details:

    Date:

    Have you ever had medical insurance refused, or offered subject to special conditions?:
    YesNo

    Details:

    Date:

    Have you ever been refused employment, or had your employment terminated for health reasons?:
    YesNo

    Details:

    Date:

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    EQUALITY OPPORTUNTIES & DIVERSITY MONITORING FORM JOB APPLICANTS

    A. BASIC DETAILS

    Speed Care Services Limited is committed to be an equal opportunities employer and we welcome applications from all sections of the community. We will ensure that all candidates for employment are treated fairly, and in order to monitor our responsibilities and to measure our progress towards widening diversity among our workforce, we would be grateful if you would answer the simple questions in the boxes below. The information you provide will remain anonymous and is for statistical monitoring purposes only. This 2-page form will be separated from your application upon receipt and is not used as part of the applicant selection process.

    Nationality:

    Your age range: 16-2021-2526-4950-6060+

    Your marital status: MarriedSeparatedDivorcedSingleWidowed

    Your gender: MaleFemaleTransgender

    B. ETHNICITY

    Please tick the box alongside the category that you feel best describes your ethnic origin, using the classification below

    White: BritishIrishAny other white background

    Black or Black British: CaribbeanAfricanAny other black background

    Mixed race: White and Black CaribbeanWhite and Black AfricanWhite and Black IrishAny other mixed background

    Asian British: IndianPakistaniBangladeshiAny other Asian background

    Chinese: Chinese

    Any other ethnic group: Other Ethnic Group

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    C. RELIGION/BELIEF

    Please tick your religion/belief group: ChristianMuslim/IslamAdventistSikhJudaismRastafarianMormonZoroastrian/ParsiBuddhistBahá’íHinduJainismNo religionDo not wish to answer

    D. DISABILITY

    The Equality Act 2010 provides for disabled people to have a legal right to fair treatment in employment matters. When answering this question please note that the Equality Act 2010 defines a disability as “a mental or physical impairment which has a substantial and long-term adverse effect upon a person’s ability to carry out normal day-to-day activities”.

    Please tick the description(s) that you feel best describes your impairment:
    No DisabilityDyslexiaBlind/Partially sightedDeaf/Hearing impedimentWheelchair user/Mobility difficultiesMental Health conditionUnseen disability (e.g. diabetes, epilepsy, asthma)Autistic Spectrum Disorder (e.g. Asperger’s Syndrome)Personal Care SupportMultiple disabilitiesOther mobility difficultyOther disability

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    EMPLOYEE DECLARATION OF SUITABILITY

    A. EMPLOYEE PERSONAL DETAILS

    Surname:

    First Name:

    Date of Birth:

    Job Position:

    Contracted Hours/Work:

    Start Date:

    B. DECLARATION OF SUITABILITY

    Have you ever had a Criminal Records Bureau check that suggests that you are unsuitable to work with vulnerable persons?:
    YesNo

    Details:

    Start Date:

    Have you ever been disqualified or prevented from being a Care Service Provider?:
    YesNo

    Details:

    Start Date:

    Have you ever been disqualified from any registration involved, either directly or indirectly, in the provision of a Care Service?:
    YesNo

    Details:

    Start Date:

    Have you ever had a financial interest in a Domiciliary Care Service whose registration was refused or cancelled?:
    YesNo

    Details:

    Start Date:

    Have you ever been referred to the Adults Barred List, Children’s Barred List, or previous lists (SOCA etc)?:
    YesNo

    Details:

    Start Date:

    (For non-UK citizens) - Do you possess the appropriate documentation that confirms your Right to Work in the U.K.? :
    YesNo

    Details:

    Start Date:

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