POSITION APPLIED FOR?

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A: PERSONAL DETAILS
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Your name (Title (Mr/Mrs/Miss/Ms/other, Full Name)

Address (including postcode)

Telephone (include Private, Business, Mobile)

Your email (Please indicate if this address is Private or Business)

National Insurance Number

Do you need a permit to work in the UK?
YesNo

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B: DRIVING RECORD
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Current Driving Licence
YesNo

Do you have regular use of a car
YesNo

If yes, please state make, model, and year

Current driving license type
PROVISIONALFULLPSVNONE

Driving License (Valid from_____ to_____)

Details of current endorsements

Do you have any driving-related prosecutions / fixed penalties / endorsements or similar currently pending?
YesNo

If yes, please provide details

Have you ever been disqualified from driving?
YesNo

If yes, please provide details

Have you ever had insurance refused?
YesNo

If yes, please provide details

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C: EDUCATION & PROFESSIONAL TRAINING (from year 11)
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Education Centre (school, college etc) - in each section, please state Dates and Qualifications Gained:

1.Secondary Education (secondary school)

2.Higher Education (university / college / polytechnic)

3.Further Education (Professional Training)

4.Membership of Professional Organisations

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D: LANGUAGES
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Please state all languages (other than English) Indicate the level e.g. SPOKEN / FLUENT / WRITTEN / READ

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E: PERSONAL DBS CERTIFICATES
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If the position you are applying for (whether paid or voluntary) is listed in Schedule 1, Part II of the Rehabilitation of Offenders Act (Exceptions) Order 1975, we are entitled to ask Exempted Questions as defined by Section 113(5) of the Police Act 1997 about you. We are required to check a DBS Certificate in relation to any person who is a Care Manager or Care Worker. If your application is successful and before your appointment is confirmed, you will be required to submit a personal current and valid DBS Certificate for our inspection.

Having a criminal record will not necessarily bar you from working with us. This will depend upon the nature of the position and the circumstances and background of your offences. We observe the “Code of Practice for Registered Persons and Other Recipients of Disclosure Information” published through the Disclosure & Barring Service on behalf of the Home Office, and we will provide you with a copy of it upon request.

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F: EMPLOYMENT HISTORY
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Please provide details of all employment, beginning with your present or most recent job first. For each job, please state the following:

- Dates of employment (from & to)
- Employer
- Salary
- Position(s) held
- Reason for leaving

Employment History

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G: VOLUNTARY & COMMUNITY WORK EXPERIENCE
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Please provide details of all voluntary & Community experience, please state the following:
- Dates of employment (from & to)
- Organisation
- Position(s) held
- Duties

Voluntary & Community Work Experience

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H: JOB FLEXIBILITY
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I am prepared to work the following
FULL-TIMEPART-TIMESHIFTS

If PART-TIME please indicate preferred hours:

Details of any other work which you will continue to undertake if you are offered this Job Position:

Please provide details of any outstanding holidays to be taken:

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I: REFERENCES
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Please provide details of 3 referees who we may approach with regards to this Job Application. These referees must not be members of your family, and one must be your present or most recent employer:

Reference 1 (Please provide, name, address, telephone number, and occupation)

Reference 2 (Please provide, name, address, telephone number, and occupation)

Reference 3 (Please provide, name, address, telephone number, and occupation)

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J: DECLARATION BY JOB APPLICANT
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ANY PERSON, UPON SUBSEQUENT EMPLOYMENT, THAT IS FOUND TO HAVE KNOWINGLY SUPPLIED FALSE OR MISLEADING INFORMATION, OR HAS DELIBERATELY WITHHELD RELEVANT INFORMATION, MAY BE SUBJECT TO DISCIPLINARY PROCEEDINGS WHICH MAY RESULT IN DISMISSAL

I have read and understood the information supplied to me in relation to this Job Position, and the information requested in this Job Application Form. I confirm that all information supplied by me is true and correct to the best of my beliefs.

I give the prospective employer the right to follow up all references and to make any other job-related enquiries as may be deemed necessary.

Sign your name here

Date Signed

KEIGHLEY CARE COMPANY LTD IS AN EQUAL OPPORTUNITIES EMPLOYER

The sole criterion for selection of applicants will be suitability for the Job Position, regardless of gender, background, culture, ethnic denomination, religious affiliation, marital status or disability.

Data Protection Act 1998: Your signature on this document gives us the right, under the Data Protection Act 1998 to process the information you have given, including data of a sensitive nature, relating to your application for employment. Any processing of the data by us will be in accordance with our Policy and the processing principles set out in the Act. Application forms of unsuccessful candidates will be destroyed after 6 months in accordance with our Record-keeping Policy.

Further information