Application Form | Assure Care Homes

Join Assure Care homes

APPLICATION FORM

Thank you for choosing Assure Care Homes as your next potential employer.

IMPORTANT
Failure to complete the application form fully or accurately may mean your application is delayed or rejected

Section 1 - The Role
Home Applying For
Role Applying For
Contract Type	Full Time (37.5 - 45 hrs per week)BankPart Time (min. 24 hours per week)
Number Of Hours Wanted
Shift Pattern	DaysWaking NightsEither
How Did You Hear About This Vacancy?
Section 1 Complete	I Have Read And Completed Section 1

Section 2 - Personal Information
Applicant First Name(s)
Applicant Surname
Previous Names (Supply Documentary Evidence e.g. Marriage Certificate, Deed Of Name Change etc.)
Preferred Name
Mobile Number
Email Address
National Insurance Number
Important Note: Minimum age legislation dictates that care workers in general must be 18 years old or older.
Are You Aged 18 Or Over?	YesNo
Current Address & Postcode	Postcode:
Date Moved Into This Address
Have You Been At The Above Address For Over 5 Years?	YesNo
For Criminal Record check purposes, addresses covering the five years up to the application date must be supplied. If necessary, please fill out additional information in section 10.
5 Year Address History
Previous Address 1
Postcode
Month And Year Moved In
Month And Year Moved Out
Previous Address 2
Postcode
Month And Year Moved In
Month And Year Moved Out
Previous Address 3
Postcode
Month And Year Moved In
Month And Year Moved Out
Please Continue In Section 10 If Required
Section 2 Complete	I Have Read And Completed Section 2

Section 3 - Driving & Transport
Do You Hold A Driving Licence?	YesNo
Driving Licence Type	Full UKAutomatic UKInternational
How Long Have You Held This Licence?
Date Entered The UK
Country Driving Licence Issued
Please list any points, fines or endorsements here – including dates
How Do You Plan To Commute To Work?
Section 3 Complete	I Have Read And Completed Section 3

Section 4 - Education, Training & Professional Membership
NOTE: Please Include Any Overseas Education.
Secondary School Name
Town/City
Dates Attended	Start: End:
Qualifications Gained
College Name
Town/City
Dates Attended	Start: End:
Qualifications Gained
University Name
Town/City
Dates Attended	Start: End:
Qualifications Gained
Further Training & Qualifications
Qualification Gained
Date Awarded
Qualification Gained
Date Awarded
Qualification Gained
Date Awarded
Section 4 Complete	I Have Read And Completed Section 4

Section 5A - Current/Most Recent Employer
Information must cover the whole of your working life to date from leaving secondary education, include any overseas work history. If you have any additional employment to add please use the additional information section. State the reasons for any breaks in employment.
Current Or Most Recent Employer Name/Company
Company Address
Postcode
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can we approach this employer for a reference? Delete as appropriate. NOTE: We will not approach employer for a reference until you have signed a written offer of employment	YESNO
Section 5A Complete	I Have Read And Completed Section 5A

Section 5B - Previous Employers
NOTE: Most Recent First.
Employer 1
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Employer 2
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Employer 3
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Employer 4
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Employer 5
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Employer 6
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Employer 7
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Employer 8
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Employer 9
Previous Employer Name/Company
Company Address
Phone Number
Email Address
Your Job Title
Start Date Of Employment
End Date Of Employment
Reason For Leaving
Can We Approach This Employer For A Reference?	YESNO
Section 5B Complete	I Have Read And Completed Section 5B

Section 6 - Character Reference
Please give us details of a character reference. PLEASE NOTE: This cannot be a family member.
Name
Relationship To You
Address
Postcode
Email Address
Phone Number
Can we take up this reference prior to interview?	YESNO
Section 6 Complete	I Have Read And Completed Section 6

Section 7 - Assistance With Interview & Assessment
This information will not be used in reaching a decision on whether to offer employment.
Do you require us to make any special arrangements for you to participate in the recruitment process? E.g. large print forms or additional time to complete forms. Delete as appropriate.	YESNO
If yes, please give details.
Section 7 Complete	I have read and completed section 7

Section 8 - Capacity To Work In The UK
Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK? Delete as appropriate.	YESNO
If yes, please give details. (e.g. asylum application pending decision, current visa expiry date etc)
If you are successful in the application, would you require sponsorship or a work permit prior to taking up employment? Delete as appropriate.	YESNO
Section 8 Complete	I Have Read And Completed Section 8

Section 9 - Criminal Record and Safeguarding
Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975 This post is covered by the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975 because it involves working directly with children or young people. You are required to declare whether you have any criminal convictions (or cautions or bind-overs) including those which are "spent". The amendments to the Exceptions Order 1975 (2013 and 2020) provide that certain spent convictions and cautions are 'protected' and are not subject to disclosure to employers and cannot be taken into account. Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and Barring Service website: DBS Filtering Guidance Please complete the following questions, taking into account the DBS filtering guidance.
Do you have any convictions, cautions, reprimands or final warnings that are not "protected" as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013 and 2020)?	YESNO
If Yes, please give details including date of each conviction, pending hearing, reprimand or warning, the offence, the sentence and the police force or court involved on a separate sheet, place the sheet in a sealed envelope marked for the attention of the Chair of the shortlisting panel and enclose it with a copy of this form.
Are you included in any list of people barred from working with children by the Disclosure and Barring Service (DBS) or the Teaching Regulation Agency?	YESNO
If Yes, please give details including dates, on a separate sheet, place the sheet in a sealed envelope marked for the attention of the Chair of the shortlisting panel and enclose it with a copy of this form.
Note: Workers of The Home are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. You may not be eligible for work in a care setting if you are on the DBS Register(s).
Section 9 Complete	I Have Read And Completed Section 9

Section 10 - Additional Information
Additional Address History
Additional Employment History
Additional Gap In Employment History
Anything Else You Would Like Us To Know?
Section 10 Complete	I Have Read And Completed Section 10

Section 11 - Declaration & Signature
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 may not 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. By my signature, I authorise Assure Care Homes 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.
PLEASE REMEMBER TO SIGN FORM HERE
Signature
Date

Join Assure Care homes

Section 1 - The Role

Section 2 - Personal Information

5 Year Address History

Section 3 - Driving & Transport

Section 4 - Education, Training & Professional Membership

Further Training & Qualifications

Section 5A - Current/Most Recent Employer

Section 5B - Previous Employers

Section 6 - Character Reference

Section 7 - Assistance With Interview & Assessment

Section 8 - Capacity To Work In The UK

Section 9 - Criminal Record and Safeguarding

Section 10 - Additional Information

Section 11 - Declaration & Signature

IMPORTANT – READ BEFORE SIGNING