Application Form for Employment

Care Success Services is an equal opportunities employer and welcomes applications from all. We apply objective scoring to our recruitment and selection process and advise you to look to the job description and person specification for guidance as to the requirements of the job role to which you are applying.

Information provided to us on this form will be treated as confidential personal information which will be handled in line with the Data Protection Act

Employment Opportunities*

Application for the position of: *

How/Where did you see the position advertised?

Personal Details*

Title*

Forename(s)*

Address*

Surname*

Postcode*

Telephone no.*

E-mail address*

Interview*

Are you available for interview within 7 working days of applying? *

YesNo

If no, please provide your earliest available date(s) for interview.

If you have a disability, please tell us if there are any ‘reasonable adjustments’ we can make to assist you in
your application or with our recruitment process.*

Driving

Do you have a valid driving licence?

YesNo

Please provide details of any endorsements

Do you have access to a car for work purposes?

YesNo

Do you have or will you obtain business use insurance?

Yes I haveYes I will obtain for my start dateNo

Current/Most recent employment*

Name of employer*

Position Title*

Employer address*

Start Date*

Salary*

Postcode*

Contract type*

Tel. No.*

Date of leaving or notice required*

Reason for leaving*

Position Responsibilities:*

Employment History* (most recent first)

Please provide a minimum of ten years’ employment history unless you have fewer years of employment. Please indicate what you were doing in any gaps in your employment.

Previous Employment 1:*

Name and address of employer*

Job Title*

Duties:*

Employment Started*

Employment Ended*

Reason for leaving*

Previous Employment 2:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

Previous Employment 3:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

Previous Employment 4:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

Previous Employment 5:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

Previous Employment 6:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

Previous Employment 7:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

Previous Employment 8:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

Previous Employment 9:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

Previous Employment 10:

Name and address of employer

Job Title

Duties:

Employment Started

Employment Ended

Reason for leaving

References*

You are required to provide a minimum of 2 references; one must be from your current or most recent employer. If you have come directly from education, please provide a referee from your last place of education or training. If you have previously worked in health and social care or with vulnerable adults or children, please provide reference details for all these employers using the extra reference tables.

When stating an employer for a reference please provide their business address, not their private address.
Relatives and friends may not be used as a referee.
References will only be contacted after an offer of employment has been made.

Referee 1 *

Please indicate referee type:*

Name of referee*

Relationship to you i.e. line manager*

Referees job title*

Name of company*

Contact tel. no.*

Email address*

Address including postcode*

Referee 2 *

Please indicate referee type:*

Name of referee*

Relationship to you i.e. line manager*

Referees job title*

Name of company*

Contact tel. no.*

Email address*

Address including postcode*

Professional memberships

The position requires the post holder to be a member of a number of professional associations and to hold specific licences as detailed as per the job description/Person Specification

Membership 1:

Licence/Professional Association name

Date of issue
Held since (date)

Membership level / licence detail

Date of expiry

Membership 2:

Licence/Professional Association name

Date of issue
Held since (date)

Membership level / licence detail

Date of expiry

Membership 3:

Licence/Professional Association name

Date of issue
Held since (date)

Membership level / licence detail

Date of expiry

Convictions and the Disclosure and Barring Service

This position is exempt from the Rehabilitation of Offenders Act 1974. As such you are required to disclose both spent and unspent convictions as you will be working in an area which is categorised as “Regulated Activity”. Any job offer made to you will also be provisional subject to receipt of a satisfactory Enhanced Disclosure and Barring Certificate.

Conviction / Caution /Reprimand/ Warning

Spent or unspent

Date of conviction

Date will be spent

Failure to reveal information relating to convictions that you are required to identify could lead to withdrawal of an offer of employment. If you are appointed, this non-disclosure may later lead to your dismissal.

Any applicants who disclose convictions will be treated fairly and will be provided with the opportunity to evidence their suitability for the post for which they are applying.

Any information provided will be kept confidential and will only be used in relation to your application. Only convictions relevant to the post for which you are applying will be considered.

Disclosure and Barring Certificate*

The position to which you are applying is subject to an enhanced DBS Check.

Do you have a DBS certificate? If yes, what is its issue date?*

YesNo

DBS certificate issue date

Have you registered for the online DBS update service?*

YesNo

If you have a disclosure, is this standard or enhanced?*

YesNo

Do you give permission for us to access your online DBS information?*

YesNo

Qualifications

The role is subject to essential qualifications as listed on the Job Description. Please list all qualifications you hold. Please enter your most recent qualifications at the top and work backwards through dates achieved.

Qualification 1:

Name of Qualification

Subject(s) covered

Level of qualification & Grade achieved

Date qualification awarded