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.

Position Applied For:

Applicants Details

Title:

Surname:

Forenames:

Address:

County:

Post Code:

email:

Current citizen of EU?

Home Tel:

Mobile Tel:

National Insurance Number:

Do you need a work permit:

Next of Kin

Name:

Address:

County:

Relationship:

County:

Post Code:

Telephone:

email:

Travel

Do you have a driving license ?

Do you have any endorsements?

Is your car available for work use?

If you have endorsements, please give details:

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

Name and Address of Employer:

Duties:

Start Date:

End Date:

Reason for Leaving:

Name and Address of Employer:

Duties:

Start Date:

End Date:

Reason for Leaving:

Name and Address of Employer:

Duties:

Start Date:

End Date:

Reason for Leaving:

Name and Address of Employer:

Duties:

Start Date:

End Date:

Reason for Leaving:

Further information relating to employment record:

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.

Name of Employer:

Contact Name:

Telephone:

Name of Employer:

Contact Name:

Telephone:

Name of Employer:

Contact Name:

Telephone:

School / Qualification Record

Name of School:

Start Date:

End Date:

Qualifications:

Name of School:

Start Date:

End Date:

Qualifications:

Notes:

Courses and Training (most recent first)

Course Location:

Subjects Covered:

Start Date:

End Date:

Skills relevent to Work:

Course Location:

Subjects Covered:

Start Date:

End Date:

Skills relevent to Work:

Notes:

References

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

Company:

Reference Name:

Telephone:

email:

Address:

Post Code:

Previous Employer

Company:

Reference Name:

Telephone:

email:

Address:

Post Code:

Previous Employer

Company:

Reference Name:

Telephone:

email:

Address:

Post Code:

Criminal Record

REHABILITATION OF OFFENDERS ACT 1974 - NOTICE TO OFFENDERS

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.

Do you have any convictions to disclose:

Have you been convicted of a criminal offence or received a caution, warning or reprimand?

Date of Conviction:

Details:

Notes:

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

Name:

Date:

Please Confirm :

By Confirming Here you agree to the above declaration

HEALTH DECLARATION

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?

Tuberculosis, asthma, bronchitis or any disease of the lungs:

Date:

Details:

Heart disease or disorder, strokes or high blood pressure :

Date:

Details:

Osteoarthritis, Rheumatoid Arthritis, or other painful inflammatory conditions:

Date:

Details:

Back trouble i.e. slipped disc, lumbago or other mobility difficulties:

Date:

Details:

Any neurological disorders e.g. Multiple Sclerosis or Epilepsy:

Date:

Details:

Diabetes Type 1 or 2 or any other blood sugar disorders:

Date:

Details:

Tuberculosis, asthma, bronchitis or any disease of the lungs:

Date:

Details:

Skin disease e.g. eczema or dermatitis:

Date:

Details:

Any known allergies:

Date:

Details:

Recurrent stomach troubles, gastric disorders/vomiting:

Date:

Details:

A hernia:

Date:

Details:

Any hearing defects/difficulties in either ear:

Date:

Details:

Eye disease (inc. Colour blindness), visual difficulties :

Date:

Details:

Mental health complaints e.g. depression, Post Traumatic Stress Disorder, Bi-Polar Disorder:

Date:

Details:

In addition have you

Had any surgical operations in the last twelve months or are you awaiting any surgical operations or hospital appointments:

Date:

Details:

Received medical treatment during the past three months or are you on a waiting list for such treatment:

Date:

Details:

Received any immunisation or vaccines in the last twelve months:

Date:

Details:

Been diagnosed with any contagious illness or disease during the last twelve months:

Date:

Details:

WORKING TIMES REGULATIONS DECLARATION

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

I (Name):

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 Agree to the above:

Date:

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

I (Name):

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 Agree to the above:

Date:

DECLARATION

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 am fit and healthy mentally and physically to carry out my duties safely:

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.

Name:

Date: