Please complete this application form.

1. Personal details

 
Surname(*) Telephone Number (Home)
Forename/s(*) Telephone Number (Mobile)
Title(*) Telephone Number (Work)
Address(*)
Postcode(*) Email(*)
Date of Birth(*) Place of Birth(*)
Nationality(*) National Insurance Number
 
Do you have the right to work in UK?(*)
Note: the company will require proof of this right before an offer of employment can be confirmed - e.g. Birth Certificate and/or any other appropriate document required to confirm your right to work in the UK as required by the Asylum and Immigration Act 1996.
 
Do you have a clean, current driving licence?(*) Have you a car/access to a car for business?(*)
 

2. Education

 
From To Name of School Examination Taken & Qualification Gained - Specify Grade
1.
2.
3.
4.
5.
 

3. Further / Higher Education

 
From To Name of Institute (State if Full or Part Time) Subject Taken and Qualification Gained (Specify Grade and Degree Class Obtained)
1.
2.
3.
4.
5.
 

4. Membership Professional Organisation

 
Date Joined Institute/Organisation Grade of Membership (Where Appropriate)
1.
2.
3.
4.
5.

5. Employment Record (please list chronologically, starting with current or last employer)

 
Name and Address of Employer and Nature of Business From To Job Title Final Salary
1.
2.
3.
4.
5.
 

6. Training e.g. NVQ or equivalent

 
Details of training courses attended and awards achieved, including dates, if appropriate
Have you undertaken the following training:
  Yes / No Date attended Certificate
Moving and Handling
Infection Control
Adult Protection
Medication
Food Hygiene
Basic First Aid
Health & Safety Work
 

7. Suitability For This Position

 
Please detail your suitability for this position under the relevant headings below:
Experience
Patient/Client group e.g. Dementia, Stroke
 

8. Disability Discrimination Act 1995

 
Section 1 of this Act describes a disabled person as a person with a 'physical or mental impairment which has a substantial or long-term effect on his/her ability to carry out normal day-to-day activities'.
If yes, do you require any special arrangements to be made to assist you is called for interview?
If yes, please provide details
 

9. References

 
Please give the details of TWO work related reference and one character including your current and most related post
Work references 1
Work references 2
Name Name
Position Position
Company Company
Address Address
Telephone Telephone
Email Email
Nature of Relationship Nature of Relationship
Character references
 
Name    
Position    
Company    
Address    
Telephone    
Email    
Nature of Relationship    
 

10. Rehabiliation of Offenders Act 1974

 
If the position you are applying for (whether paid or voluntary) is listed in schedule 1, part II of the Rehabilitation of Offenders Act(Exceptions) Order 1975. Live-In Comfort is entitled to ask Exempted Questions by section L 1 3 (5) of the Police Act 1997 about you. From July 2002 Live-In comfort is required by The Domiciliary Care Agencies Regulation 2001 to acquire a criminal record certificate in relation to any person who is a care manager or a care worker.

This means that if your application is successful we will procure from the Disclosure and Barring Service a criminal record certificate relating to you before your appointment is confirmed. You are however encouraged to tell us about your criminal record before we procure a criminal record certificate.

Having a criminal record will not necessarily bar you from working with us. This will depend on the nature of the position and the circumstances and the background of your offences.

Have you been found Guilty of a Criminal Offence?
Have you received a police caution?
If you have answered yes to any of the above please provide details.
If you have subscribed to the disclosure services update service can we obtain an online status check?
 
If yes, complete below:
Certificate Number:    
This is the number on the Certificate that is referred to as the Certificate Number
Applicant's Surname on Certificate:    
Date of Birth on Certificate:    

11. Verification Information

 
I certify that all information which I have provided is correct. I understand that any false information given may result in a job offer being withdrew.
Full Name(*)    
Signature(*)    
Date(*)    
Image Verification(*) captcha
   
     
 
(*) Required Information