Employment Application

Position you are applying for:

How did you learn of this vacancy?

Date of publication or website address:

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Personal Details

First Name(s):

Title:

Surname:

Middle Name(s):

Marital Status:

Date of Birth:

Gender:

NI Number:

Nationality:

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Contact Details

House No & Street:

Town:

Postcode:

Home Tel No:

Mobile No:

Email Address:

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Next of Kin

Full Name:

Relationship:

Landline:

Mobile Number:

Do you own a car you can travel to work in?

Yes

No

Do you hold a full driving licence that allows you to drive a car in the U.K.?

Yes

No

Do you have any endorsements (points) on your driving licence?

Yes

No

If ‘yes’ then please give details (no. of points, dates, etc.):

Having read the job description, are there any aspects of the role that you are unable to undertake?

Yes

No

If ‘yes’ please give details:

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Medical Details

Do you require special facilities for interview?

Yes

No

What notice period do you have to give your current employer?

If ‘yes’ please give details:

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Education and Training

SECONDARY SCHOOL/COLLEGE/ UNIVERSITY ATTENDED

Full or Part Time?

Full

Part Time

Date From:

Date To:

COURSE(S) TAKEN OR CURRENTLY STUDYING

EXAMINATION RESULTS (INCLUDING GRADES)

SECONDARY SCHOOL/COLLEGE/ UNIVERSITY ATTENDED (additional)

Full or Part Time?

Full

Part Time

Option 3

Date From:

Date To:

COURSE(S) TAKEN OR CURRENTLY STUDYING

EXAMINATION RESULTS (INCLUDING GRADES)

Other relevant training courses attended:

Professional Qualifications:

Professional body:

Details of UK registration:

Name & Pin No:

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Career History: most recent employment first – please explain any gaps in dates

Date From:

Date To:

Position Held:

Current Employer Name & Address:

Brief Job Description:

Reason for leaving:

Date From:

Date To:

Position Held:

Previous Employer Name & Address:

Brief Job Description:

Reason for leaving:

Date From:

Date To:

Position Held:

Previous Employer Name & Address:

Brief Job Description:

Reason for leaving:

Date From:

Date To:

Position Held:

Previous Employer Name & Address:

Brief Job Description:

Reason for leaving:

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References:

Please note: friends and relatives cannot be used as acceptable to use as references.

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1st –Referee’s Details (this should be a professional referee)

Name of referee:

Job Title:

Name of Company/Employer:

Company's Full Postal Address:

Mobile/Tel No:

Email Address:

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2rd –Referee’s Details (this can be a personal referee/professional referee)

Name of referee:

Job Title:

Name Of Company/Employer:

Company’s Full Postal Address:

Mobile/Tel No:

Email Address:

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Miscellaneous

Are you related to, or in a relationship with any staff already working for DarSarno Care Services?

Yes

No

If 'yes' please give details:

Have you worked for DarSarno Care Services before?

Yes

No

If 'yes' please give details:

If you are offered the position will you continue to work in any other capacity?

Yes

No

If 'yes' please give details:

Have you ever been subject to any disciplinary action in your current employment or have any disciplinary action pending?

Yes

No

If 'yes' please give details:

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Mandatory Training – You must provide evidence of attendance, dates and course content if you have already undertaken these courses

Understanding your role:

Yes

No

Date of Course:

Your personal development:

Yes

No

Date of Course:

Duty of care:

Yes

No

Date of Course:

Equality and diversity:

Yes

No

Date of Course:

Work in a person-centred way:

Yes

No

Date of Course:

Communication:

Yes

No

Date of Course:

Privacy and dignity:

Yes

No

Date of Course:

Fluids and nutrition:

Yes

No

Date of Course:

Awareness of mental health, dementia and learning disabilities:

Yes

No

Date of Course:

Safeguarding adults:

Yes

No

Date of Course:

Safeguarding children:

Yes

No

Date of Course:

Basic life support:

Yes

No

Date of Course:

Health and safety:

Yes

No

Date of Course:

Infection prevention and control:

Yes

No

Date of Course:

Moving and Handling:

Yes

No

Date of Course:

Medication:

Yes

No

Date of Course:

Food Hygiene:

Yes

No

Date of Course:

Data Protection:

Yes

No

Date of Course:

Customer Service:

Yes

No

Date of Course:

Dementia Awareness:

Yes

No

Date of Course:

Mental Capacity Act (2005) and Deprivation of Liberty:

Yes

No

Date of Course:

Recording and Report Writing:

Yes

No

Date of Course:

Other courses: Give Details :

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Other training may be required to work with certain clients. Please ask for further details during your interview.

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Disclosure and Barring Service (DBS)

DarSarno Care Services complies fully with the Disclosure and Barring Service (DBS) code of practice and we treat all applicants for positions fairly. Please note that having a criminal record will NOT necessarily bar you from working for us, however, non-disclosure at this time may affect your application with us.

The work for which you are applying is exempt from the Rehabilitation of Offenders Act 1974, because it involves substantial opportunity for access to children and vulnerable adults. You are therefore required to declare details of any spent, unspent convictions, cautions, reprimands or warnings you may have save where the spent conviction or caution is protected under the Exceptions Order 1975 (2013). The information you give will be regarded as confidential and will only be disclosed in relation to healthcare appointments.

The amendments to the Exceptions Order 1975 (2013) 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.

DarSarno Care Services will arrange for a check to be made with the police for the existence and content of any criminal record in your name. Any information received from the police will be kept in strict confidence and will be destroyed immediately the selection process is completed.

The disclosure of a criminal record, or other information, will not debar you from appointment unless DarSarno Care Services considers, or is advised, that it renders you unsuitable for appointment. In making this decision DarSarno Care Services and the authority will consider the nature of the offence, how long ago and what age were you when it was committed and any other factors, which may be relevant.

Failure to declare any spent, unspent convictions, cautions, reprimands or warnings which are not protected may well disqualify you from appointment, or result in your appointment being terminated when the discrepancy comes to light.

I give my consent for DarSarno Care Services to perform a DBS Status Check on an ongoing basis (as per relevant policies and procedures), to perform an Early Confirmation check, and for DarSarno Care Services to obtain a copy of my DBS Certificate for their records and any managed service or client records. I shall bring a copy of DBS Certificate to DarSarno Care Services if requested. Should I wish to withdraw my consent for DarSarno Care Services to perform a Status Check, I shall give DarSarno Care Services written notice of such withdrawal.

Please note the cost of the DBS Application and DBS Update Service is to be met by you.

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) by SI 2013 1198?

Yes

No

Are you currently under investigation for a criminal act?

Yes

No

If you answered yes to either of the above questions, please give full details including the date and reason:

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Right to Work in the UK

Please complete this section of the form, regardless of your nationality, as it is a legal requirement. If you are an overseas national or require a work permit to work in the UK please include copies of supporting documentation.

Are you eligible to work in the United Kingdom?

Yes

No

Do you require a work permit to be employed in the United Kingdom?

Yes

No

Are you subject to visa, time or work permit restrictions?

Yes

No

Your entitlement for working in the UK is based upon what status?

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Equal Opportunities Monitoring

DarSarno Care Services is committed to equal opportunities during the recruitment process. In order to find out how well we are doing we need to collect monitoring data. This monitoring form is voluntary but the information we collect here is very useful to us, as it helps us to make sure that we are an inclusive employer and to find out if our workforce is diverse. The information you supply on this form will be kept confidential and will not be used during the recruitment process. DCS has an Equal Opportunities Policy which is available upon request.

Gender:

Age:

Marital Status:

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Ethnicity

How would you describe your ethnic origin?

White:

British

Irish

Other white background

If other please specify:

Mixed:

White and black Caribbean

White and black African

White and Asian

Other mixed background

If other please specify:

Asian or Asian British:

Indian

Pakistani

Bangladeshi

Other Asian background

If other please specify:

Black or black British:

Caribbean

African

Other black background

If other please specify:

Other ethnic groups:

Chinese

Other ethnic group

If other please specify:

I would prefer not to disclose this information

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Disability

The Equality Act 2010 defines a disabled person as someone who has a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.

Do you consider yourself a disabled person as defined by the Disability Discrimination Act?

Yes

No

Prefer not to say

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Religion or Belief

Select one:

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Sexual Orientation

Select one:

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Data Protection

I hereby consent to information relating to me being processed by the Company (DarSarno Care Services and its subsidiaries) in order that it may properly carry out its duties, rights and obligations. I understand that such processing will principally be for personnel, administrative and payroll purposes.

I also understand that the term ’processing’ includes the obtaining, recording or holding of information or data carrying out any operation or set of operations on the information data, including organising, altering, retrieving, consulting, using, disclosing, combining or destroying the information data.

From time to time the Company is audited by outside contracted clients and Agencies (i.e. NHS/CQC) that requires your consent. I consent to outside clients and outside agencies having access to information held on my personal file for inspection purposes.

For the purpose of recruitment decisions some or all of the information contained in this application form maybe shared with clients for the purpose of finding suitable assignment.

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By checking, I agree to all of the above information.

Date:

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If you are invited for an interview, you will be required to provide the following:

Proof of identity
Passport or birth certificate only
Documentation of your National Insurance Number e.g. NI card, P60, P45/ P46 or other official Inland Revenue document
Two forms of proof of current address are required for the Criminal Records Bureau disclosure e.g. utility bill or bank statement
Certificates for training undertaken and qualifications gained
Immunisation record

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Non EU citizens please provide the following:

Evidence of your right to work in the UK: visa, work permit and Home Office confirmation
Evidence that you are a student if studying in the UK.

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For Nurses please provide the following:

NMC statement of entry
PIN card
Post qualification certificates relevant to practice

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Registration Form Declaration:

Please read before checking the box below.

I agree that DarSarno Care Services retains the right to hold this registration form and any other data required to process it and pass onto any authorised third party and the details held within. I also agree to use all reasonable efforts to assist in order to comply with the Data Protection Act 1998.

I understand that all information supplied on this application form will be kept strictly confidential and will only be used for the purpose of selection and administration. The information I have given in this application is to the best of my knowledge, true and accurate. I accept that any false or misleading statements may be sufficient cause for rejecting my application, or if employed, may lead to my dismissal.

Opt-In

By checking, I agree to the above declaration

Date:

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Employment Application Form