Application Form

Step 1 of 11

Education

Examinations, Qualifications*(Required)

(All qualifications will be subject to a satisfactory check).

School / College / University

Date From:

Date To:

Examinations, Qualifications*

Training Courses

(attended or completing (evidence of attending courses is required)

Subject

Location

Date

Details

Professional Memberships / Registrations

Name of Organisation

Registration Number

Renewal Date

Details

Attach Supporting Documents

Drop files here or

Max. file size: 256 MB.

Employment History

Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained. Use a separate attached sheet if required; please sign the sheet(s)

Current / Most recent employer

Start Date

End Date

Salary

Job Role

Employer Name

Reason for Leaving

Contact Name

Duties:

Address

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

Postcode

Telephone

Employment History

Start Date:

End Date:

Salary

Job Role

Employer Name

Reason for Leaving

Contact Name

Duties:

Address

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

Postcode

Telephone

Additional Employment History

Start Date:

End Date:

Salary:

Job Role:

Employer Name:

Reason for Leaving:

Contact Name:

Duties:

Address:

Postcode:

Telephone:

Email:

Explanation of Gaps

(Use this section to detail any gaps in employment and why)

Detailed Employment Gaps

References

Please provide names, addresses and telephone numbers for referees below who we may approach for a reference. In line with CQC requirements, we require references (or other satisfactory evidence as the employer may determine) from all previous employers concerned with the provision of services relating to health or social care, or children or vulnerable adults which should include details of why their employment came to an end (note that this is not time limited). If your previous employment does not concern the provision of services relating to health or social care, or children or vulnerable adults, you must provide references from your two most recent employers. Please provide two-character references if you are unable to obtain two professional references, e.g. in the case of an applicant who has been raising children for ten years. All will be contacted. Therefore, please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.

Referee One

Full Names(Required)

Contact Name Business Name

Address(Required)

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

Postcode

Phone(Required)

Email(Required)

Capacity in which known(Required)

Referee Two

Full Names(Required)

Contact Name Business Name

Address(Required)

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

Postcode

Phone(Required)

Email(Required)

Capacity in which known(Required)

Additional References

Contact Name:

Address:

Postcode:

Telephone:

Email:

Professional / Character:

Capacity in which known

Safeguarding / Ex-Offenders Declaration

Safeguarding / Ex-Offenders Declaration: Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest confidence.

The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. Medicare Support and Housing LTD undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

*Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country?(Required)

Yes

*Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country?(Required)

Yes

Privacy Statement

We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to us holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you). When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles. We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant post. You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Registered Manager to discuss.

Declaration

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that can seek clarification regarding professional registration details.

Full Name(Required)

Prefix First Last

Signature(Required)

Consent(Required)

I agree to the privacy policy.

I agree that any deliberate omission, falsification or
misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if
employed. Where applicable, I consent that can seek clarification regarding professional registration details.

Date(Required)

Supporting Statement

Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe particular strengths and talents that set you apart from others as well as including skills gained from work, home and other activities.

Your Supporting Statement

Application Form

Personal Details

Section

Education

Employment History

Current / Most recent employer

Employment History

Explanation of Gaps

References

Referee One

Referee Two

Safeguarding / Ex-Offenders Declaration

Privacy Statement

Declaration

Supporting Statement

Optional Section

Ethnic Origin:

Gender:

Please answer the following questions

Applicant's Declaration

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