APPLICATION FOR EMPLOYMENT POSITION APPLIED FOR
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APPLICATION FOR EMPLOYMENT POSITION APPLIED FOR: ……………………………………………………………………………… APPLICANTS PERSONAL DETAILS: FIRST NAME(S) ………………………………………… SURNAME (S) …………………………………………… MAIDEN NAME (S) ………………………………………… PREVIOUS NAME (S) …………………………………………… ADDRESS: ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… …………………………………………POST CODE…………………………………… D.O.B……………………………… NATIONALITY: ……………………………………………………………………………………………… ARE YOU REGISTERED AS A DISABLED PERSON?……………………………... NATIONAL INSURANCE NUMBER …… …… …… …… …… MARITAL STATUS: MARRIED SINGLE DIVORCED COHABITING NEXT OF KIN DETAILS FULL NAME……………………………… TELEPHONE NUMBER………………… ADDRESS………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………POST CODE………………………………… DRIVING Do you hold a current driving licence?………………………………………………… Do you have use of a car?……………………………………………………………… Do you have any driving convictions over the last 5 years?………………………… If so, please give details…………………………………………………………………. EMPLOYMENT HISTORY Previous employment – starting with most recent (10 year period) Employer’s name & address position held dates to & from reason for leaving ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ………………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… ……………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………………………… TRAINING AND EXPERIENCE NVQ 2 – Date of qualification ………………… Certificate supplied……………… NVQ 3 – Date of qualification ………………… Certificate supplied……………… Or other relevant qualification Date of qualification ……………… Certificate supplied ………………………….. Date of qualification ……………… Certificate supplied ………………………….. Moving & Handling Health & Safety Infection Control Food Hygiene Fire Safety Awareness First Aid Elder Abuse Awareness Other – please specify Date……… Date……… Date……… Date……… Date……… Date……… Date……… Date……… Experiences Capacity obtained Certificate supplied……………… Certificate supplied……………… Certificate supplied……………… Certificate supplied……………… Certificate supplied……………… Certificate supplied……………… Certificate supplied……………… Certificate supplied……………… Period of time Mental Health Learning Disabilities Children & families Support work Nursing/Residential home Hospital Care in the Community TRAINING AND EXPERIENCES Please give any other details of your4 knowledge, skills and experience (including outside interests, voluntary work and employment scheme attendance) which you feel are relevant to this post ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… Experience Questionnaire Please sign the boxes which reflect your experience, the capacity in which you gained your experience (ie professional/personal ) and the service user group eg older people, children, people with learning disabilities Experience PART 9: Capacity obtained User Group Signature Strip Wash /Bath/Shower Use of bath aids Mouth / Oral hygiene Care of feet Monitoring pressure areas Care of hair Wet and dry shaving Emptying Colostomy bag Emptying Catheter bag Hygiene & use of a convene (Male Sheath) Use of bedpan / Commode Care of Bladder/Bowel Clients Respiration Clients Temperature Bedridden Clients Observation of Clients Health/ Welfare Confidentiality Completing Care Log sheets Reporting Concerns Terminally ill Dementia Heart Complaints Strokes Diabetes Epilepsy Mentally ill Clients Care of Minors Use a Hoist Use of walking aids Dressing and undressing Clients Prompting Medication Light housework/Laundry Shopping/Pension collection Preparation of meals Moving & Handling First aid Health & Safety Contagious Diseases OTHER DETAILS: LANGUAGES: (please identify your ability to speak, read or write and identify the level) ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… HOBBIES OR INTERESTS: ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… EMPLOYMENT HISTORY: (i) COMPANY: ……………………………………………………………………………………………… REFEREE: ……………………………………………………………………………………………… CONTACT NUMBER: ……………………………………………………………………………………………… POSITION HELD: ……………………………………………………………………………………………… PERIOD EMPLOYED: ……………………………………………………………………………………………… RESPONSIBILITYIES/DUTIES: ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… REASON FOR LEAVING: ……………………………………………………………………………………………… ……………………………………………………………………………………………… MAY WE CONTACT THEM: (please circle as appropriate) YES NO (ii) COMPANY: ……………………………………………………………………………………………… REFEREE: ……………………………………………………………………………………………… CONTACT NUMBER: ……………………………………………………………………………………………… POSITION HELD: ……………………………………………………………………………………………… PERIOD EMPLOYED: ……………………………………………………………………………………………… RESPONSIBILITYIES/DUTIES: ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… REASON FOR LEAVING: ……………………………………………………………………………………………… ……………………………………………………………………………………………… MAY WE CONTACT THEM: (please circle as appropriate) YES NO WORK AVAILABILITY Please five details of any other organization that you are currently employed by………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… Please list below the hours below that you undertake for them (circle as appropriate) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning Morning Morning Morning Morning Morning Morning Afternoon Afternoon Afternoon Afternoon Afternoon Afternoon Afternoon Evening Evening Evening Evening Evening Evening Evening Night (10 – 8) Night (10 – 8) Night (10 – 8) Night (10 – 8) Night (10 – 8) Night (10 – 8) Night (10 – 8) Please indicate the hours below that you are available to work for Sterling Care & Support (circle as appropriate) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning Morning Morning Morning Morning Morning Morning Afternoon Afternoon Afternoon Afternoon Afternoon Afternoon Afternoon Evening Evening Evening Evening Evening Evening Evening Night (10 – 8) Night (10 – 8) Night (10 – 8) Night (10 – 8) Night (10 – 8) Night (10 – 8) Night (10 – 8) Signature…………………………… Date……………………………… MEDICAL QUESTIONAIRE Have you ever suffered from any of the following, if so please give details: 1)Tuberculosis, asthma, hay fever, bronchitis, chest complaints, or sore throats 2)Chest Pains, Heart Condition or raised blood pressure? 3) Epilepsy, fits, attacks of giddiness, Migraine? 4) Depression, Mental illness or nervous breakdown 5)Diabetes, thyroid or other gland trouble? 6)Dermatitis, skin sensitivity (allergies psoriasis, or eczema? 7)Hearing problems, ear infections? 8) Varicose Veins? 9)Gastric disorder or stomach trouble (Irritable Bowel) 10)Poor eyesight, do you wear glasses/contact lenses? 11)Back injury, Back problems or back pain? 12)Have you any reason to believe you may be infected by any communicable disease? 13) Have you ever had bad salmonella or food poisoning? 14)Have you ever suffered from or come into contact with Hepatitis B? 15)Have you ever had any major operations or illnesses? 16)Have you ever been deemed medically unfit? 17) Are you currently receiving any treatment or medication? 18)Are you registered under the Disabled Persons Act? 19)Do you smoke? 20)Is there any other relevant illness which may affect your performance in this job? I confirm that I have answered the above truthfully and honestly and understand that any false statements may result in instant dismissal. Signed……………………………… Date………………………………… MEDICAL DECLARATION Please comment on the following: How is your general health?…………………………………………………………… Have you ever had an accident at work?……………………………………………… If yes please give details………………………………………………………………… ……………………………………………………………………………………………… Have you ever had a back injury?……………………………………………………… If yes please give details…………………………………………………………………………………… Do you have any back problems at present? ………………………………………… If yes please give details………………………………………………………………… ……………………………………………………………………………………………… Please list any injuries or aches and pains, which may prevent you from carrying out your duties…………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… Have you been immunized against: TB ………………… HEP B…………….. Signed……………………………… Date………………………………… Please write a brief statement as to the state of your physical & mental health ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE: (if yes then please give details) ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… DECLARATIONS: I declare that I understand that this is an application for a position only and does not imply any promises of employment on behalf of the company. I the undersigned applicant hereby declare that all of the information on this application employment form is accurate and true and I understand that any falsehood or omission on my part may be grounds for future dismissal from the position or withdrawal of an offer of employment. Signed ……………………………………… on the …/…/… Print name ………………………………….
