Tel: 01902 810174 (Wolverhampton) 01902 810074 (Staffs & Shrops)
First name (required) Surname (required) Email Address (required) Date of Birth (required) Nationality Ethnic Origin Marital Status Gender (required) Select oneMaleFemale
Address (required) Postcode (required)
Home Number Mobile Number
National Insurance Number
What driving license do you hold?
Do you own your own vehicle? Select oneYesNo
Position (required) Select oneCommunity Care WorkerOffice Administrator
Preferred position type Full Time Part Time
Preferred Start Time AM (7am start) PM (4pm or 6pm start)
Please state which working hours you would prefer. (Listing any commitments which could restrict your working hours, please note that working alternate weekends is compulsory)
Preferred working hours
Where did you hear about this vacancy?
Name of School
Qualifications from School
Other Qualifications
Please give details of any experience and skills you have relating to the job of a care worker.
Please list names of employers since leaving school, period of working with each employer and reason for leaving. Please start with your current/most recent employer and include the address.
Employer 1: Start Date, End Date, Reason for Leaving
Employer 2: Start Date, End Date, Reason for Leaving
Employer 3: Start Date, End Date, Reason for Leaving
Employer 4: Start Date, End Date, Reason for Leaving
Employer 5: Start Date, End Date, Reason for Leaving
Current Wage
Please give the names and addresses of two referee's from your current place of work, one must be your current manager. (Must be Employment references.)
Reference 1: Company, Contact Name, Telephone Number, and Capacity in which you know the referee
Reference 2: Company, Contact Name, Telephone Number, and Capacity in which you know the referee
If the position you are applying for (whether paid or voluntary is listed is schedule 1, Part 2 of the Rehabilitation of Offenders Act Order 1975, C & S Care Services is entitled to ask Exempted Questions as defined by Section 113(5) Of the Police Act 1997 about you. From July 2002 C & S Care Services is requires by The Domiciliary Care Agencies Regulations 2001 to obtain a criminal record certificate in relation to any person who is care manager or domiciliary care worker.
This means that if your application is successful we will obtain from the Criminal Records Bureau a criminal record certificate relating to you, before your appointment is confirmed. You are, however encouraged to tell us about your criminal record before we obtain a criminal record certificate.
Do you have a procecution pending or have you ever been convicted at a court or cautioned by the police for any offence? Select oneYesNo
If YES - Please provide details below of pending prosecutions, convictions, cautions and bind over orders, including approximate date, the offence and the court or police force which dealt with the offence
Having a criminal record will not necessarily stop you working with us.
This will depend on the nature of the position and the circumstances and background of your offences. C & S Care Services Ltd. has a written policy on the recruitment of ex offenders and we will give you a copy of it on request. C & S Care Services Ltd. observes the "Code of Practice for Registered Persons and Other Recipients of Disclosure Information" published by the Criminal Records Bureau at www.crb.gov.uk on behalf of the Home Office, and we will give you a copy of it on request.
I declare that I believe that the information I have given on the above application form is true.
Signed (required)
Date (required)
Please enter the following Security Code into the box provided
