Application Form

Position Applying For*

Full Name*

First NameMiddle NameSurname

Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry

Email*

example@example.com

Phone Number

Area CodePhone Number

Mobile Phone Number

Full Driving License

YesNo

Endorsements

YesNo

If YES, please give further details including dates:

Are you involved in any activity which might limit your availability to work or your working hours e.g., local government?

YesNo

If YES, please give full details

Are you subject to any restrictions or covenants which might restrict your working activities?

YesNo

If YES, please give further details including dates:

Are you willing to work overtime and weekends if required?

YesNo

Please give details of any hours which you would not wish to work:

Are you aged over 18?

YesNo

It is a criminal offence for barred individuals to apply to work in a regulated activity with children, young people or adults at risk. Are you on a barred list?

YesNo

If offered employment, we are required to check your up to date DBS status before you are permitted to start work.

Do you have a DBS certificate?

YesNo

If yes, are you a current member of the Update Service?

YesNo

If yes, do you consent to this Update Service check being made by the Company?

YesNo

Do you have any convictions, cautions, reprimands or final warnings that are not "protected" as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198? (A copy of the Company’s Equal Opportunities Policy and Disclosure and Disclosure Information Policy is available on request. These reflect the DBS Code of Practice).

YesNo

If YES, please give full details

If offered employment, you will be required to complete a Medical Questionnaire. Are you prepared to undergo a medical examination before employment?

YesNo

Have you ever worked for the Company before?

YesNo

If YES, please give full details

Have you applied for employment with this Company before?

YesNo

Do you need a work permit to take up employment in the U.K.?

YesNo

How much notice are you required to give to your current employer

Education (1/4)

Education (2/4)

Education (3/4)

Education (4/4)

Education (Extra)

Please supply any other information you feel is suitable for the role

Please give details of membership of any technical or professional associations

Please list languages spoken and the level of competence

Employers

Are you currently employed?

YesNo

Name of present or last employer

Name of Previous Employer

Address

Street Address

Street Address Line 2

CityCounty

Postcode

Telephone Number

Area CodePhone Number

Nature of business

Job title & brief description of duties

Reason for Leaving?

Length of servce:

Start Date

MonthDayYear

End Date

MonthDayYear

Interests, Achievements, and Leisure Activities

(e.g. hobbies, sports, club memberships)

Supplementary Information

Please set out below any further information to support your application (e.g. past achievements, future aspirations, personal strengths)

Reference 1

Name of Reference

Relationship

Address

Street Address

Street Address Line 2

CityCounty

Postcode

Phone Reference 1

Email Reference 1

Reference 2

Name of Reference

Relationship

Address

Street Address

Street Address Line 2

CityCounty

Postcode

Phone Reference 2

Email Reference 2

Source of Application

How did you hear of this vacancy?

I declare that the information given in this form is complete and accurate. I understand that any false information or deliberate omissions will disqualify me from employment or may render me liable to summary dismissal. I understand these details will be held in confidence by the Company, for the purposes of ongoing personnel administration and payroll administration in compliance with the Data Protection Act 1998. I undertake to notify the Company immediately of any changes to the above details.

Given the nature of the job for which I have applied, I understand that any offer of employment will be subject to information on my criminal record being disclosed to the Company by the Disclosure Barring Service. (Please note that the amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are 'protected' and are not subject to disclosure to employers, and cannot be taken into account. Guidance and criteria on the filtering of these cautions and convictions can be found at the Disclosure and Barring Service website.)

I have been given a copy of the Company’s Equal Opportunities and Diversity Policy, which includes information relating to the recruitment of ex-offenders.

I consent to having the above information stored by Springfield Care Homes in relation to my enquiry*

YesNo

Application Form:

Employment Desired:

Personal Information:

Education:

Employment Details

Present or Last Employer

References:

Declaration