Personal Details

Passport Photo

First Names

Surname

Maiden Name/Previous Name

Marital Status

Gender

Address

Date of Birth

Postcode

Place of Birth

Nationality

DBS Number
DBS date of issue

NI Number
Mobile Number

Email Address

Are you a Driver?YesNo

Own TransportYesNo

How long have you had a licence?

Any EndorsementsYesNo

Are you a United Kingdom (UK), National YesNo*

*If no, please detail your current immigration status and the relevant visa currently held (including Visa number)

Are you related to any of our current members of staff or Service Users? YesNo

Equality Act 2010 - Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a “substantial” and “long-term adverse effect” on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-under-equality-act-2010.

For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?

Please can you please give details of addresses that you have resided at within the last 5 years starting with current.

Addresses in full

Current Address in full

Postcode

Date From:

Date to:

Previous Addresses

Address

Postcode

Date From:

Date to:

Education *(All qualifications will be subject to a satisfactory check).

School

Date From:

Date to:

Examinations, Qualifications*

College

Date From:

Date to:

Examinations, Qualifications*

University

Date From:

Date to:

Examinations, Qualifications*

Training Courses attended or completing (evidence of attending courses is required)

Subject

Location

Date

Details

Professional Memberships / Registrations

Name of Organisation

Registration Number

Renewal_Date

Details

Employment History

Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained. Use a separate attached sheet if required; please sign the sheet(s)

Current / Most recent employer

Start Date

End Date

Salary

Job Role

Employer Name

Contact Name

Reason for Leaving

Duties

Address

Postcode

Telephone

Email

Employment History

Start Date

End Date

Salary

Job Role

Employer Name

Contact Name

Reason for Leaving

Duties

Address

Postcode

Telephone

Email

Employment History continue(Fill this if required)

Start Date

End Date

Salary

Job Role

Employer Name

Contact Name

Reason for Leaving

Duties

Address

Postcode

Telephone

Email

Start Date

End Date

Salary

Job Role

Employer Name

Contact Name

Reason for Leaving

Duties

Address

Postcode

Telephone

Email

Explanation of Gaps Use this section to detail any gaps in employment and why

References

Please provide names, addresses and telephone numbers for referees below who we may approach for a reference.

You must provide references from your two most recent employers. In line with CQC requirements, we require references covering your last five years employment. If you have not had more than one employer in the last five years, we require a further reference. Please provide two-character references if you are unable to obtain two professional references, e.g. in the case of an applicant who has been raising children for ten years. All will be contacted, therefore, please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.

Referee One

Contact Name

Business Name

Address

Postcode

Telephone

Email

Capacity in which known

Referee Two

Contact Name

Business Name

Address

Postcode

Telephone

Email

Capacity in which known

Referee Three

Contact Name

Business Name

Address

Postcode

Telephone

Email

Capacity in which known

Referee Four

Contact Name

Business Name

Address

Postcode

Telephone

Email

Capacity in which known

Additional Referee

Contact Name

Business Name

Address

Postcode

Telephone

Email

Capacity in which known

Safeguarding / Ex-Offenders Declaration

Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest confidence.

The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. SANA CARE SERVICES LIMITED undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.

Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country? YesNo
Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country? YesNo

COVID-19 Vaccinations

Please note this section is required by law if the role you are applying for involves direct contact with Service Users.

The Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) (No2) Regulations 2021 make it mandatory for a health and social care worker who has direct, face to face contact with Service Users to be fully vaccinated against COVID-19 from 1 April 2022.

Are you fully vaccinated against COVID-19 or exempt from vaccination? YesNo
Are you able to evidence your vaccination or exemption status using the NHS COVID pass? YesNo

Privacy Statement

We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to us holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you). When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles.

We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant post.

You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Registered Manager to discuss.

Monitoring Information

1. Have you ever travelled to the UK. YesNo

Dates of Travel

Visa type

Length of Stay

Date of travel

Date of Departure

2. Have you ever been denied a VISA to the UK? YesNo
If Yes, Give details

3. Have you ever denied a VISA to any European or western Country e.g: USA, CANADA, etc YesNo
If Yes, Give details

4. Have you ever been deported from any of the European or Western Countries YesNo
If Yes, Give details

Supporting Statement

Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe particular strengths and talents that set you apart from others as well as including skills gained from work, home and other activities.

Values Based Screening Questions

This should be completed before attending any interview. It will be discussed as part of the interview process.

If I was a Service User, I would like:

I believe that the Service User’s family and Relatives would like the following:

I believe that I can support a Service User because:

As a member of the team, I would feel valued when:

I believe that a good relationship between me and the Service User depends upon:

I believe that I learn best when:

I believe that a good working team is made by:

I believe that my role in relation to the Service User is:

My other beliefs and values relevant to my job role are:

Position Applied For

Location

Work Preference
Full TimePart TimeBank

Hours Requested

I understand this role may include Shift work, Unsociable Hours, Lone working involved.
YesNo

Please fill your availability below

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday