Application Form

First name (required)

Surname (required)

Email Address (required)

Date of Birth (required)

Nationality

Ethnic Origin

Marital Status

Gender (required)

Address (required)

Postcode (required)

Home Number

Mobile Number

National Insurance Number

What driving license do you hold?

Do you own your own vehicle?

Position (required)

Preferred position type
Full TimePart Time

Preferred Start Time
AM (7am start)PM (4pm 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?

EDUCATION AND QUALIFICATIONS

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.

EMPLOYMENT HISTORY

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

REFERENCES

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

CRIMINAL RECORD CERTIFICATES

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 Disclosure and Barring Service (formerly known as 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 prosecution pending or have you ever been convicted at a court, cautioned by the police for any offence or charged with a civil conviction?

If YES - Please provide details below of pending prosecutions, convictions, cautions, bind over orders or civil convictions, 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.

DECLARATION

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 Disclosure and Barring Service (formerly known as Criminal Records Bureau) at https://www.gov.uk/government/organisations/disclosure-and-barring-service 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)