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01276 804421 
01344 292256 
Please complete this application form online. It is a very long form and is very detailed. There is no ability to save the information you have entered and return to complete it later. 
Alternatively you may wish to download the application form in either of the formats below, printing off the PDF document and posting it to us, or complete in Word and either email or post it to us. 

Applicants Details 

Next of Kin 


Employment Record 

Full employment record ( most recent first , then go backwards ). 
Please explain any gaps in employment i.e. studying, unemployment, raising family etc. in the "Further Notes" section below 
If any of the above positions involved working with Vulnerable Adults or Children, please indicate below contact details of someone who can verify your reason for leaving. 

School / Qualification Record 

Courses and Training (most recent first) 


Please give details of two / three senior individuals who may be approached for references. Where possible these should be your current and last employer and at least one must be from previous employment 

Current Employer 

Previous Employer 

Previous Employer 

Criminal Record 
The position for which you are applying is exempt from Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act (Exemption Order 1975). This means that you are not entitled to withhold information relating to any convictions you may have had. 
Angel Heart Home Care is required under the Health & Social Care Act 2008, to obtain a criminal record check. This will be processed through the Disclosure and Barring Service (DBS). This was formed by merging together the functions of the Criminal Records Bureau (CRB) and the Independent Safeguarding Authority. This has to be completed in relation to any person who is a domiciliary care worker. Therefore, ifbyour application is successful we will need to obtain this Disclosure before your appointment is confirmed. 
Please advise us of any criminal convictions (excluding minor road traffic offences), cautions, reprimands or warnings you have received before we obtain an Enhanced Criminal Record Bureau Disclosure. Having a criminal record will not necessarily mean that you will not be able to work in the care sector but will depend on the nature of the position, the circumstances and background of your offences. 
Any information should be given on a separate sheet and sent with this application form. This information will be treated as strictly confidential and will not necessarily preclude you from employment. 
I declare all information I have provided regarding the Rehabilitation Act 1974 is true 
Task Ability Schedule - Please tick each task in which you are experienced: 
Due to the nature of the work that you will undertake with Angel Heart Home Care and the frequent requirement for a certain level of physical and mental fitness, we require you to provide us with certain details of your medical history as a part of the application process. The information requested here will only be considered in accordance with the provisions of the Equality Act 2010. 
Have you in the last three years suffered from any of the following? 
In addition have you  
If you do wish to work more than 35 per week, it is necessary to sign the form below to show that you are available 
confirm that I want to be able to work more than 35 hours per week and that I will give you adequate notification in writing should I wish to reduce these hours to less than 48 hours. 
If you do not wish to work more than 35 hours per week, it is necessary to sign the form below to show that you are not available 
confirm that I want to be able to work more than 35 hours per week and that I will give you adequate notification in writing should I wish to reduce these hours to less than 48 hours. 
I declare that the information I have provided on this application form is true. I understand that all personal information about me relating to my employment with Angel Heart Home Care is confidential. 
I hereby give my permission for the information I have supplied to be made available, on a need to know basis, the Care and Quality Commission and those responsible in Social Services. 
I agree to a medical examination or report, or to respond to a request for further information, if I am offered employment by Angel Heart Home Care. If necessary I authorise Angel Heart Home Care to contact my own doctor, consultant or specialist to whom I have been referred. I accept that any information submitted by Angel Heart Home Care as a result may be used to determine any modifications, if any, to be made in the interest in allowing me to perform my duties in a safely. 
I certify that I have answered all questions truly and fully. 
I am not aware of any health reason that would or may affect my working capability. 
I hereby agree that I shall not disclose any confidential information to any third parties, unless I have written consent from Angel Heart Home Care. 
I understand that, should I disclose any confidential information, it may lead to disciplinary action being taken. If any aspect of this declaration is false I may be dismissed. 
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