Job Application Form
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Important
Successful applicants will be asked to provide an Enhanced Disclosure Certificate, detailing all criminal convictions against their name, as supplied on application from The Disclosure Barring Service. Disclosure information will not be used for any other purpose than in connection with this application and a criminal record will not necessarily be a bar to employment.
Position you are applying for
Job Title
(Required)
Posted at
Job Reference (if applicable)
Personal Information
Name
(Required)
Dr
Miss
Mr
Mrs
Ms
Prof.
Rev.
Prefix
First
Last
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
(Required)
Email
(Required)
Nationality
Place of Birth
National Insurance Number
Spoken Languages
List all the spoken languages excluding English. Click on the + Button to add more rows.
Add
Remove
Do you have any relatives/friends currently employed or receiving care from by Supported Living Services Ltd?
(Required)
Yes
No
Please provide more details
Driving
Please answer if stated as an essential or desirable requirement on the person specifications.
Do you have a full UK Driving Licence?
Yes
No
How long have you had a licence?
Do you have access to a car?
Yes
No
Rights to Work
Are you a United Kingdom (UK), European Community (EC), European Economic Area (EEA) National
(Required)
Yes
No
Please detail your current immigration status and the relevant visa currently held (including Visa number)
Do you require a Sponsor's Licence?
(Required)
Yes
No
Your Availability
Confirm your availability
(Required)
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Add
Remove
Employment History
Please list in order (most recent job first) the organisations you have worked for, full-time and part-time, paid and unpaid, including relevant voluntary work and include any periods of non-employment.
Previously employment history
(Required)
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From / To
Employer
Job Title / Main Duties
Reason for leaving
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Remove
Is there any Gaps in your employment history?
Yes
No
Explanation of Employment Gaps
Use this section to detail any gaps in employment and why
Education
Please include details of studies undertaken and qualifications achieved from secondary education onwards:
List
(Required)
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Dates attended
School, College, or University
Course Title
Qualifications and Grades obtained
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Remove
Training
Do you hold current certified certificates in?
Essential Training
Mental Health Awareness
Equality & Diversity
Manual Handling
Infection Control
Fire Awareness
Medication Administration
Safeguarding Adults
Care Certificates
Challenging Behaviour
Personal Care
First Aid at Work
Food Hygiene
QCF Level 2
QCD Level 3 or above
Other Training
Please include details of any other training including NVQs, short courses, company training. Click on the + Button to add more rows.
Dates attended
College or Firm
Title of Training Programme or Course
Qualifications and grades obtained
Add
Remove
RELEVENT EXPERIENCE AND SKILLS
The information you provide in this section is important in assessing your application. Please use the space to explain your reasons for applying for the post, showing how your skills, experience and personal qualities relate to the job requirements as set out in the job description and person specification. These may have been gained through previous employment, voluntary/community work, spare time activities or training. Please include details of membership of relevant professional associations, and anything else which you think is appropriate to this application.
Additional Information
Health Declaration
Regulation 21, Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 requires that all employees who work in Health & Social Care are both physically and mentally fit to undertake their duties.
Have you had the following vaccinations?
If yes, you will be asked to provide a certificate.
Hepatitis B
Rubella
Tetanus
TB (Tuberculosis)
Polio
Sickness
How many days were you absent from work due to sickness in the last year?
(Required)
Additional Information
Have you ever suffered from: Allergies, eczema, dermatitis or other skin troubles?
(Required)
Yes
No
Please provide more information
Do you suffer from: Epilepsy, migraine, asthma, angina, heart trouble or any condition requiring long-term medical help or an ongoing programme of medication?
(Required)
Yes
No
Please provide more information
Have you ever suffered from: Mental illness including anxiety, stress, depression or nervous debility?
(Required)
Yes
No
Please provide more information
Have you ever required treatment for: Hernia or rupture, rheumatism, back problems, slipped disc, sciatica or Repetitive Strain Injury (RSI)?
(Required)
Yes
No
Please provide more information
Do you suffer from: Diabetes, ulcers, stomach or other intestinal disorders?
(Required)
Yes
No
Please provide more information
Equality Act 2010
Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a “substantial” and “long-term adverse effect” on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-under-equality-act- 2010.
For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?
(Required)
Yes
No
Prefer not to say
Safeguarding / Ex-Offenders Declaration
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. Supported Living Services 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
No
Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country?
(Required)
Yes
No
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.
Employment Reference
(Required)
You are required to provide at least 1 Employment Reference. Click on the + Button to add more rows.
Contact Name
Position
Relationship
Business Name
Full Address
Telephone
Email
Add
Remove
Character Reference
(Required)
You are required to provide at least 1 Character Reference. Click on the + Button to add more rows.
Contact Name
Position
Relationship
Business Name
Full Address
Telephone
Email
Add
Remove
Submit
Declaration
(Required)
I declare that all the information I have given on this application form is true and accurate, to the best of my knowledge. Please note that if you give untrue or inaccurate information any employment contract may be invalidated and you may be subject to disciplinary action or dismissal.
I agree and confirm the declaration below.
Name
First
Last
Supporting Information
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.
Statement
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