Care Worker Application Form
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Care Worker
Application Form

Personal Information

Prefix

Name(s) *

Surname *

Email Address *

Phone Number *

Position Applied For

National Insurance Number *

Are You Over 18 *YesNo

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Other Information

School, College, University, etc

How long have you been carer / support / nurse?

Qualifications obtained

Any other relevant qualifications?

Can you work both days and nights? (tick appropriate) *DayNight

Can you work on weekends as well? *YesNo

Can you work more than your contracted hours? *YesNo

Work Times Regulations Declaration

Are you eligible to work in the UK? *YesNo

Do you consider yourself disabled under the Disability Discrimination Act 1995? *YesNo

I am eligible for employment in the UK and I am physically and mentally fit for work. to my knowledge all the information I have provided on this application form is true and complete record. I also acknowledge that the contract of employment Act 1972 applies to this application.

No file chosen

Date

Do you have a current full driving licence?YesNo

Do you have any endorsement?YesNo

Reference 1

Prefix

Name(s) *

Surname *

Email Address

Phone Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Employer's / Company's Name

Occupation

How long have you known this person and in what capacity? *

Reference 2

Prefix

Name(s) *

Surname *

Email Address

Phone Number

Employer's / Company's Name

Occupation

How long have you known this person and in what capacity? *

Next of Kin

Prefix

Name(s) *

Surname *

Email Address

Phone Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Relation *

Employment History

Have You Ever Been Employed? *YesNo

Employer's / Company's Name

Job Title

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date Start

Month

Day

Year

Still Employed?YesNo

Date Ended

Month

Day

Year

Salary

GBP

Reason For Leaving

Brief description of duties and key achievements

Healthcare Trainings & Own Illnesses

Do you have any healthcare training certification? *YesNo

Please provide information about training attended plus certificates

Health & SafetyBasic First AidMoving & HandlingPrevention & Infection ControlFood HygieneMedicationBasic Life Support

Upload Certificates

Drag and Drop (or) Choose Files

Do you have or have you ever suffered from any of the following?

Dermatitis/skin disorders/psoriasis/eczemaTuberculosis/bronchitis/pneumonia/pleurisyEyesight/hearing/wear glasses or hearing aidAsthma/hay feverHeadaches/migraines/dizzinessDiabetes/epilepsyBack injury/recurrent infectionHepatitis/jaundice/kidney problemsVaricose veins/foot problems

Rehabilitation of Offenders Act 1974

Have you ever been convicted of a criminal offence? *YesNoYou are advised that you are not entitled to withhold information about convictions which are regarded as SPENT UNDER THE ACT . this is due to the nature of the work involved which renders the post exempt from sec.4 (2) of the Act in accordance with the rehabilitation of Offenders Act 1974 (exceptions) order 1975

Please give details of all convictions including spent convictions and cautions

Banking Details

Bank Name

Account Name

Account Number

Sort Code

Bank Address

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Care WorkerApplication Form

Personal Information

Other Information

Care Worker
Application Form