Application Form (Offered)

Image of two people sat at a table in a canteen setting, chatting over a cup of tea, highlighting companionship services. Social and Assisted Visits Application form our care team

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PERSONAL DETAILS

Name(Required)

Title First Last

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

National Insurance Number(Required)

Mobile Number(Required)

Tel Home

EDUCATION

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

School/College – Name & Location

Examinations Taken / Level and Grade

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

School/College – Name & Location

Examinations Taken / Level and Grade

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

School/College – Name & Location

Examinations Taken / Level and Grade

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

School/College – Name & Location

Examinations Taken / Level and Grade

PROFESSIONAL QUALIFICATIONS/TRAINING COURSES – original certificates required

Date

MM slash DD slash YYYY

Qualification / Other

Grades

Date

MM slash DD slash YYYY

Qualification / Other

Grades

Date

MM slash DD slash YYYY

Qualification / Other

Grades

Date

MM slash DD slash YYYY

Qualification / Other

Grades

WHY ARE YOU INTERESTED IN THIS POSITION WITH HOMECARERS LTD?

Why are you interested in this position with Homecarers Ltd? Please add any relevant experience you may have to the position applied for.(Required)

Have you ever worked for Homecarers Ltd before? If so, in what role and when?(Required)

Have you been made aware of this position by a current employee of Homecarers Ltd? If so, who?(Required)

WHEN CAN YOU WORK?

Tick the shifts you are available to work.

What shifts can you work?(Required)

7am-2pm

7am-6.30pm

3.30pm-6.30pm

3.30pm-11.15pm

6.30pm-11.15pm

Are there any days you can not work? Please specify reasons.(Required)

Please note: It is compulsory that all support workers are able to commit to working alternate weekends. As a minimum requirement, hours will be the same as during the weekdays. Staff can select to work extra on their working weekend or planned weekend off.

Are there any times that you are not available?(Required)

What date are you available to start work?(Required)

Do you require any assistance due to disabilities?(Required)

Please give details:

EMPLOYMENT HISTORY

Due to the nature of employment, it is required that you state ALL employment history from leaving school, you must include ALL periods of employment and explain fully any breaks in employment. This is statutory for all support staff. Please start with your most recent employment.

Date (From)

MM slash DD slash YYYY

Date (To)

MM slash DD slash YYYY

Company name and address

Job titles and responsibilities

Reason for leaving

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

Company name and address

Job titles and responsibilities

Reason for leaving

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

Company name and address

Job titles and responsibilities

Reason for leaving

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

Company name and address

Job titles and responsibilities

Reason for leaving

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

Company name and address

Job titles and responsibilities

Reason for leaving

Date (To)

MM slash DD slash YYYY

Date (From)

MM slash DD slash YYYY

Company name and address

Job titles and responsibilities

Reason for leaving

Are you currently in employment?(Required)

Yes

What is your notice period?

REFERENCES

(references will only be requested following your acceptance of position with the company) Please provide a minimum of two referees, one of which must be your most recent employer. For employment references, they should be your most recent employers (no relatives). If you cannot provide two employment references, you must provide one employment reference and two character references. If you have not worked in the last 5 years you should provide 3 character references Character references – work colleagues, neighbours, friends of the family, business acquaintances, and clients. References will be applied for once you have accepted a formal offer.

Employee / Character (Reference 1)

Referee Name (Reference 1)

Job title / Relationship (Reference 1)

Company Name If Applicable (Reference 1)

Address (Reference 1)

Email Address (Reference 1)

Phone Number (Reference 1)

Employee / Character (Reference 2)

Referee Name (Reference 2)

Job title / Relationship (Reference 2)

Company Name If Applicable (Reference 2)

Address (Reference 2)

Email Address (Reference 2)

Phone Number (Reference 2)

Employee / Character (Reference 3)

Referee Name (Reference 3)

Job title / Relationship (Reference 3)

Company Name If Applicable (Reference 3)

Address (Reference 3)

Email Address (Reference 3)

Phone Number (Reference 3)

Employee / Character (Reference 4)

Referee Name (Reference 4)

Job title / Relationship (Reference 4)

Company Name If Applicable (Reference 4)

Address (Reference 4)

Email Address (Reference 4)

Phone Number (Reference 4)

Employee / Character (Reference 5)

Referee Name (Reference 5)

Job title / Relationship (Reference 5)

Company Name If Applicable (Reference 5)

Address (Reference 5)

Email Address (Reference 5)

Phone Number (Reference 5)

Employee / Character (Reference 6)

Referee Name (Reference 6)

Job title / Relationship (Reference 6)

Company Name If Applicable (Reference 6)

Address (Reference 6)

Email Address (Reference 6)

Phone Number (Reference 6)

PLEASE SPECIFY AND TICK IN THE BELOW THE AREAS YOU ARE ABLE TO WORK IN?

Are you able to work in Chester, covering the following areas: Chester, Malpas, Tarporley, Ellesmere Port, Neston(Required)

Yes

Are you able to work in Winsford, covering the following areas: Winsford, Middlewich, Northwich, Helsby(Required)

Yes

Are you able to work in our Extra Care Housing, covering the following areas: Abbotswood, Devapoint, Kingswood, Hallwood(Required)

Yes

If you are applying for a specific role that has been advertised, please indicate the shifts, days & area that were stated in the advert:

DRIVING LICENSE & DBS

Do you have a full UK driving license?(Required)

Yes

Do you have access to your own vehicle?(Required)

Yes

Do you currently have/have held a full enhanced DBS?(Required)

Yes

If you have a transitional DBS we will need the barcode and photocopy – Please provide below

REHABILITATION OF OFFENDERS (EXCEPTIONS) ACT 1979

In accordance with the rehabilitation of Offenders (Exceptions) Act 1979 all convictions including those deemed spent must be disclosed (not including traffic offences). This includes convictions, cautions, reprimands, or final warnings(Required)

Have you ever been convicted of a criminal offence?(Required)

All successful applicants must undergo and DBS Disclosure. On sending this form you are agreeing to a DBS being carried out on offer of employment.

Yes

DECLARATION

In signing this form, you are giving your permission for the following: You personal data to be stored and processed for the purpose of arriving at a selection decision and, for the successful candidate, future personnel administration. Permission for your data to be shared with our training provider Richmond Training to enable them to prepare documents and assessments for your induction and any subsequent training and relevant funding. You give the employer the right to apply for references (following acceptance of job offer) and to secure all additional information about you, if position related. You hereby release from your liability the employer and the representatives for seeking such information and all other persons, corporations and organisations for furnishing such information. I understand that the position applied for/offered will be subject to the satisfactory outcome of references, proof of my right to work in the UK, a completed DBS and proof of qualifications. I declare that all information provided is accurate at the time of signing and understand that if I have entered any false or misleading information, this may lead to termination of any employment offered. By submitting this form, you are agreeing to Home Carers Ltd's Privacy Policy.(Required)

Agree? (Required) *

Yes

Date(Required)

Consent(Required)

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