Apply Online – Northern Community Care

Position Applied For *

Location

Hours Requested

Work PreferenceFull TimePart TimeBank

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

Please select your availability below

Personal Details

First Name *

Last Name *

Maiden Name

Previous Name

Marital Status

Gender

Street Address

Address Line 2

City

County/State/Region

ZIP / Postal code

Country

Date Of Birth *

Nationality *

NI Number

Phone Number *

Email *

How long have you have had a license?

Any EndorsementsYesNoN/A

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

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-actu00022010.

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? *YesNoRather not say

If Yes

Education

Examinations, Qualifications(All qualifications will be subject to a satisfactory check).

School / University

Date To

Date From

Qualifications

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

Subject

Location

Date

Details

Professional Memberships / Registrations

Organisation

Registration Number

Renewal Date

Details

Attach Supporting Documents

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

Starte Date

End Date

Salary

Job Role *

Employer Name

Reason for Leaving

Contact Name

Duties

Address *Street Address

Address Line 2

City

County/State/Region

ZIP / Postal code

Country

Telephone *

Email

Explanation of Gaps

(Use this section to detail any gaps in employment and why)

Detailed Employment Gaps

References

Please provide names, addresses and telephone numbers for referees below who we may approach for a reference. In line with CQC requirements, we require references (or other satisfactory evidence as the employer may determine) from all previous employers concerned with the provision of services relating to health or social care, or children or vulnerable adults which should include details of why their employment came to an end (note that this is not time limited). If your previous employment does not concern the provision of services relating to health or social care, or children or vulnerable adults, you must provide references from your two most recent employers. 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.

Referees

Full Names *

Business Name

Street *Street Address

Address Line 2

City

County/State/Region

ZIP / Postal code

Country

Capacity in which known *

Safeguarding / Ex-Offenders Declaration

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. Medicare Support and Housing LTD 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

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.

Declaration

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that can seek clarification regarding professional registration details.

Prefix

First Name *

Last Name *

Signature

Date *

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.

Your Supporting Statement *

Optional

Medicare Support and Housing LTD is committed to equality of opportunity and fair treatment in all aspects of employment. We aim to provide a working and learning environment which is free from unfair discrimination and will enable staff to fulfil their personal potential. The Equality Act 2010 protects people from discrimination and promotes equality on the basis of a number of ‘protected characteristics’. We ask for information on your ‘protected characteristics’ in order to help us monitor our performance on equality. In line with Government policy, and in accordance with the provisions of GDPR, the information you provide will be held confidentially and It will help us to comply with the law under the relevant Acts and to ensure that our employment policies and practices are fair and effective. Move Duplicate Settings Delete IMPORTANT

IMPORTANT

You do not have to complete this form. The information is given on a voluntary basis and the information provided will only be used for monitoring purposes. Please do not enter any identifying marks on this form, so that your information remains confidential. This information will be stored on a computer.

Ethnic Origin

Please indicate your Ethnic Origin

Gender

As per Equality Act 2010 *Under the terms of the Act, a disability is defined as a “physical or mental impairment which has a substantial and long-term effect on a person’s ability to carry out day-to-day activities. Do you consider yourself to have a disabilityYesNoI do not wish to disclose whether or not I have a disability

Please answer the following questions

Do you have or have you ever had any significant health problem, impairment / disability (physical or mental) or learning difficulties that may affect your ability to undertake the tasks set out in the job description of the post offered? *YesNo

Do you have or have you ever had any illness, impairment of disability that may have been caused or made worse by your work?YesNo

Have you ever left or been denied employment in an organisation on the grounds of ill health or been medically retired on the grounds of ill health?YesNo

Are you having, or waiting for any medical treatment or investigations at present?YesNo

Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?YesNo

If you answered 'yes' to any of the above questions, please provide details below:

Applicant's Declaration

Kindly select 'Yes' / 'No' as appropriate if you read and understood

I confirm that the information given above is complete and correct. I understand that any incomplete, untrue or misleading information given will entitle the employer to reject my application, withdraw any offer of employment, or, if I am employed, dismiss me without notice. *YesNo

By my signature, I give authority to the employer to contact my GP for further details regarding any of the potential health problems I have declared above. *YesNo

I agree that Medicare Support and Housing LTD reserves the right to require me to undergo a medical examination to assess my suitability for work.YesNo

I do not wish to complete the questionnaire and I do not wish to have a free health assessment. *YesNo

Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered? *YesNo

Prefix

First Name *

Last Name *

Signature

Date

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