Application Form

Excellent Care Ltd – Application Form

Position Details

Personal Details

Surname:

First Name:

Date of Birth:

Marital Status:

Nationality:

NI Number:

Address:

Postcode:

Contact Tel:

Mobile:

Email:

Passport Details

Passport Number:

Place of Issue:

Issue Date:

Expiry Date:

Visa Status:

Visa Expiry Date:

If student,please provide the course details:

Next of Kin

Name:

Relationship:

Address:

Tel:

Mobile:

Email:

Educational Qualifications

Place of Study 1:

Qualification 1:

Date Qualified 1:

Place of Study 2:

Qualification 2:

Date Qualified 2:

Place of Study 3:

Qualification 3:

Date Qualified 3:

Training

Course Name 1:

Date Attended 1:

Expiry Date 1:

Details(if necessary) 1:

Course Name 2:

Date Attended 2:

Expiry Date 2:

Details(if necessary) 2:

Course Name 3:

Date Attended 3:

Expiry Date 3:

Details(if necessary) 3:

Work Experience

From:

To:

Name Of Employer:

Type Of Business:

Job Title:

REFERENCE

Please give the names and contact details of two references.One should be your previous Employer.

Applicant Type:

Name 1 :

Job Title 1 :

Relationship 1 :

Address 1 :

Company Name 1 :

Tel 1 :

Email 1 :

Name 2 :

Job Title 2:

Relationship 2 :

Address 2 :

Company Name 2 :

Tel 2 :

Email 2 :

Equal Opportunity Monitoring Form

The information on this form will be used in total confidence and in accordance with current data protection legislation. It will help to ensure that the company properly monitors and confirms its policies relating to equality of opportunity. Information will be used for monitoring only. Our commitment aims to allow our staff to develop their skills and realize their maximum potential as individuals, without any wish on the part of the company to limit their opportunity.

PLEASE TICK THE RELEVANT BOX

Gender:

Male Female

Do you consider yourself to have a disability of some kind:

Yes No

If yes,give details:

PROTECTION OF CHILDREN AND VULNERABLE ADULTS DECLARATION

Has any Social Service Department or Police Service ever conducted an enquiry or investigation into any allegations or that you may pose an actual or potential risk to children or vulnerable adults?

Yes No

Have you ever been convicted of any offence relating to children or vulnerable adults?

Yes No

Have you ever been the subject of any disciplinary procedure or been asked to leave employment or voluntary activity due to inappropriate behavior towards a child or vulnerable adult?

Yes No

If no please sign the declaration below. If yes to any of these questions above, please give details.

REHABILITATION OF OFFENDERS

Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975. Applicants are therefore not entitled to withhold information about convictions, which for other purposes are spent under the provisions of the Act and the event of employment any failure to disclose such convictions could result in dismissal or disciplinary action by the employer. All Successful candidates will be required to obtain an enhanced disclosure report from the Disclosure and Barring Service. Have you ever been convicted of a criminal offence, or been subject to any conditional discharge, bind overs or caution?

Yes No

If no please sign the declaration below,If yes please give details

I declare that I do not possess,nor have I ever possessed a criminal conviction, not have I been subject to any conditional discharges,bindovers or cautions.

Signature: Date:

Any information contained in this form will be treated in confidence.Failure to disclose any relevant information or providing false or inaccurate information may be regarded as a breach of any subsequent contract of employment, resulting in disciplinary action and/or dismissal.

PANEL AGENCY MEMBERSHIP

If you like to work through our panel agencies in various locations please sign the declaration below. This will help you to work with different clients in various locations through our other agencies who are our partners. The related staff pay and other benefits are available through the panel agency members directly. Please tick the box below if you are interested.

I have no objections in working with the panel agencies through E care solutions.
Name: Signature:

NOTES

DECLARATION

I confirm that the information given within this form is true and accurate.I hereby give consent for this information being used for personnel administration and business purposes.

Signature: Date:
Name:

Once completed please send it to the respective branch.

Excellent Care Ltd – Application Form

Position Details

Personal Details

Passport Details

Next of Kin

Educational Qualifications

Training

Work Experience

REFERENCE

Equal Opportunity Monitoring Form

PLEASE TICK THE RELEVANT BOX

PROTECTION OF CHILDREN AND VULNERABLE ADULTS DECLARATION

REHABILITATION OF OFFENDERS

PANEL AGENCY MEMBERSHIP

NOTES

DECLARATION

FOR OFFICIAL USE ONLY(Application Check List)

Save Application

View Saved Form