Submit application form | Nightingale Home Care

The recruitment process within this organisation has a minimum of two stages.

The completion of this application form is part of stage one. This application will be reviewed and a decision made as to whether to proceed to stage two, the interview, based on this information. PLEASE COMPLETE FULLY AND IN CAPITALS.

Position applied for:

Approx. no. of hours wanted

Surname:

First name(s):

Previous surnames (Supply documentary evidence e.g. marriage certificate, deed of name change etc):

Current address:

Address Line1:

Address Line2:

Post code:

Moved to this address on (date):

Previous address Note: For Criminal Record check purposes, addresses covering the five years up to the application date must be supplied.

Post code:

Moved to this address on (date):

Telephone number(home):

Telephone number (work - will be used with discretion):

Own Transport:

How long has your licence been held?

Clean current driving licence:Endorsements:Details:

EDUCATION

School/College/University

Examinations Passed/Qualifications gained

TRAINING HISTORY/PROFESSIONAL STATUS

Date of Graduation/Qualification

Location/Details

(Please supply copies of certificates/membership details)

Notes

SHORT COURSES ATTENDED

Subjects

Location

EMPLOYMENT HISTORY

Current/most recent first. Information must cover the whole of your working life to date. State the reasons for any breaks in employment. Use a separate attached sheet if required; please sign that sheet(s).

Name and address of your most recent/last employer:

Date employed:

Nature of business:

Position held and reason for leaving:

Salary / Rate:

Name and address of Employer prior to the employer listed above:

Date employed:

Nature of business:

Position held and reason for leaving:

Salary / Rate:

Name and address of Employer prior to the employer listed above:

Date employed:

Nature of business:

Position held and reason for leaving:

Salary / Rate:

Other roles:

Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home. Please use separate sheet if insufficient space is available.

ASSISTANCE WITH INTERVIEW AND ASSESSMENT

Do you require us to make any special arrangements in order for you to participate in the recruitment process, for example, large print forms or additional time to complete forms?

If yes, please give details (This information will not be used in reaching a decision on whether to offer employment.):

Any offer of employment may be made subject to a satisfactory medical report.

GP’s name:

Tel no:

Address Line1:

Address Line2:

(Your GP will never be contacted without your permission)

IDENTITY DETAILS

National Insurance Number:

(All Applicants)

Scottish Social Services Council Registration

(Relevant Staff)

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?

If yes, please provide details.

If you are successful in the application, would you require a work permit prior to taking up employment?

Note: Minimum age legislation dictates that Care workers in general must be 16 years old or older. Please inform your interviewer immediately if you do not meet these specifications.

REFEREES

You must provide references from your two most recent employers. Please provide a character reference if you are unable to obtain two professional references e.g. in the case of an applicant who has been a stay at home mum for ten years. All will be contacted, therefore please inform the referees of the fact that you have provided their names. If you are unable to provide the required references, please discuss the matter with us.

Current or most recent Employer

Name:

Address Line1:

Address Line2:

Post code:

Tel No:

Job title:

Previous employer to the one above

Name:

Address Line1:

Address Line2:

Post code:

Tel No:

Job title:

Character reference

Name:

Address Line1:

Address Line2:

Post code:

Tel No:

Relationship to you

CRIMINAL RECORD

Workers of The Agency are subject to the Protection of Vulnerable Groups (PVG) Membership Scheme. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.
You will not be eligible for work in a Care setting if you do not have a clear PVG Check.

Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and
warnings and cautions in the space provided below.

SIGNATURE and DECLARATION – 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 cannot be offered a post until a satisfactory response has been received with respect to my PVG Check 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 PVG Check.
I understand that until a satisfactory response is received from the PVG Check, and my employment is confirmed, I will not be able to work with vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise the organisation to request a PVG Check and a criminal records check from the PVG Check, on initial employment and at any time during my employment thereafter.
I undertake to inform my employer immediately if my PVG Check 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.

Signed:

Date: