PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS AND RETURN TO:

WISTERIA CARE, VANCOUVER HOUSE, 111 HAGLEY ROAD, EDGBASTON, BIRMINGAM, B16 8LB.

  • PERSONAL DETAILS:

    (please circle which you want to work)
    (please circle which you are able to work)
  • Note: For Criminal Record check purposes, addresses covering the five years up to the application date must be supplied.
  • Language - Fluency (Good/Fair/Little)
  • EDUCATION:

  • TRAINING HISTORY/PROFESSIONAL STATUS:

  • SHORT COURSES ATTENDED

  • EMPLOYMENT HISTORY

    Current/most recent first. Information must cover the whole of your working life to date. State the reasons for any breaks in employment. Use a separate attached sheet if required; please sign used sheet(s).

  • ASSISTANCE WITH INTERVIEW AND ASSESSMENT

    Confidentiality Health Questionnaire

  • Any offer of employment may be made subject to a satisfactory medical report.

  • (Your GP will not be contacted without your permission)
  • NEXT OF KIN

  • IDENTITY DETAILS

  • CAPACITY TO WORK IN THE UK

  • Note: Minimum age legislation dictates that Care workers in general must be 16 years old or older. Please inform your interviewer immediately if you do not meet these specifications.

  • REFEREES

    You must provide references from your two most recent employers. Please provide an additional character referee. 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.

    Current or most recent Employer

  • Previous employer to the one above

  • Character reference

  • CRIMINAL RECORD

    Workers of The Agency are subject to the Care Act 2014, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.

    You will not be eligible for work in a Care setting if you are on the DBS Register(s).

  • SIGNATURE and DECLARATION – IMPORTANT – READ BEFORE SIGNING

    I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately. I understand that I cannot be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise the organisation to request a DBS Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred Care workers, or withdrawal of any registration required by my employment status.

    Declaration of Health

    By signing this application form, I declare that to the best of my knowledge I am not suffering from any infectious or debilitating medical condition. I am not aware of any reason, in relation to my health, which in anyway restricts my ability to carry out the functions and duties normally associated with the provision of healthcare or nursing care to any member of the public. I hereby confirm that I am not currently in receipt of sickness benefits. I am aware and understand that receipt of benefits whilst in employment may be a criminal offence and a breach of the company’s policies and procedures.

  • (By typing your name above, you agreed to the conditions stated above. This will serve as your electronic signature.)