Job Application Form

POSITION APPLIED FOR:

Job

Carer Social Care Children Services

PERSONAL INFORMATION:

Title:

First Name:

Surname:

DOB:

Place of Birth:

Gender

Male Female Other

Address:

Postcode:

How long have you lived at that address?

If less than five years, please give previous address:

Postcode:

Have you ever lived outside of the UK?

Yes No

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

Yes No

National Insurance No:

Tel:

Home Tel:

Email:

LEGAL & BUSINESS

Are you registered with any regulatory body?

Yes No

Name of Registration Body:

Registration Number:

Date of Registration:

Name of nearest relative:

Relationship to you:

Nearest relative address:

Postcode:

Nearest relative Home No:

Nearest relative Mobile No:

Do you hold a current driving licence?

Yes No

Do you have Business Car Insurance?

Yes No

Are you a car owner?

Yes No

What date are you available to start work?

How many hours can you work weekly?

What availability do you have?

Full time (8am-11pm) Part time (8am-6pm or 6pm-11pm) Night duty (8pm-8am).

Educational History:

Month / Year Education completed:

REFEREES

Please name two suitable* referees, at least one of whom should have knowledge of your present or most recent work as Your Line Manager/Employer. (Relatives should not be named as referees).

EMPLOYER

Month / Year Employment commenced:

Employer Title:

Employer Name:

Employer Occupation:

Employer Address:

Employer Postcode:

Employer Phone No:

Employer Email:

Can we contact this employer referee prior to interview?

Yes No

PERSONAL

Personal Title:

Personal Name:

Personal Occupation:

Personal Address:

Personal Postcode:

Personal Phone No:

Personal Email:

Can we contact this personal referee prior to interview?

Yes No

EMPLOYMENT HISTORY (Beginning with present / last Employer)

Please record ALL employers from you completed education until current position.
IF FULL DETAILS ARE NOT PROVIDED YOUR APPLICATION WILL NOT BE CONSIDERED***

Most Recent

Employer Name:

Employer Address:

Employer Telephone:

Employer Email:

Date of Employment Held From:

Date of Employment Held To:

Position Held:

Reason For Leaving:

Employment 2

Employer Name:

Employer Address:

Employer Telephone:

Employer Email:

Date of Employment Held From:

Date of Employment Held To:

Position Held:

Reason For Leaving:

Employment 3

Employer Name:

Employer Address:

Employer Telephone:

Employer Email:

Date of Employment Held From:

Date of Employment Held To:

Position Held:

Reason For Leaving:

Employment 4

Employer Name:

Employer Address:

Employer Telephone:

Employer Email:

Date of Employment Held From:

Date of Employment Held To:

Position Held:

Reason For Leaving:

If applicable provide a written explanation where there are employment gaps for our records:

Reason For Employment Gap:

From:

To:

Reason For Employment Gap:

From:

To:

Reason For Employment Gap:

From:

To:

INFORMATION KNOWINGLY OR WILFULLY WITHELD TO OBTAIN EMPLOYMENT WILL RESULT IN SUMMARY DISMISSAL***

MEDICAL HISTORY

Are you a registered disabled person?

Yes No

Are you willing to undergo a medical examination?

Yes No

PLEASE PROVIDE DETAILS OF ALL ABSENCES FROM WORK DUE TO ILLNESS OR INJURY DURING THE LAST THREE YEARS (CONTINUE ON A SEPARATE SHEET IF NECESSARY).

Number of Days:

Reason For Absence:

Number of Days:

Reason For Absence:

INDEPENDENT SAFEGUARDING AUTHORITY:

Is there any reason why you cannot work in regulated activity?

Yes No

If yes, please provide full details below:

DISCLOSURE OF CRIMINAL BACKGROUND:
Because of the nature of the work for which you have applied, this post is exempt from Article 5 of the Rehabilitation of Offenders Order Northern Ireland 1978, and the Rehabilitation of Offenders (Exceptions) Northern Ireland Order 1979 and requires that all convictions and cautions must be declared, and that no conviction can be deemed to be spent.

It is therefore necessary to ask the following questions

Have you ever been convicted of any Criminal offence?

Yes No

Are you currently the subject of police Investigation or do you have any prosecutions Pending?

Yes No

List below details of all charges, prosecutions, convictions, cautions - even if they happened a long time ago. You must include any minor matters, Including road traffic or motoring offences and any which may be pending

Please note that a disclosure of a conviction does not necessarily debar any applicant from obtaining employment

The following policies are available on request
Policy on Access NI Security on the secure storage, handling ,use , retention and disposal of disclosure Informal

Policy Statement on Recruitment of ex-offenders

I understand that if an offer of employment is made, it is subject to an Access NI check. Access NI enables organisations in Northern Ireland to make more informed recruitment decisions by providing criminal history information about anyone seeking paid / unpaid work in certain detained areas such as working with children or vulnerable adults.

For further details on Access NI and their code of practise this can be accessed on www.nidirect.gov.uk/accessni

Do you agree to an Access NI check?

Yes No

Please note that you will be expected to meet the cost of an Enhanced Disclosure Certificate.

Upload CV Optional

Do you accept:

I declare that any answers are complete and correct to the best of my knowledge.

Name:

Date:

By BelfastIT.com

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