Careers – Professional care for your loved ones

Job Position Details

Position Applied For:

Location:

Nottingham

Derby

Work Preference:

Full Time

Part Time

Bank

Hours Requested:

I understand this role may include: Shift work, Unsociable Hours, Lone working involved.

Yes

No

Personal Details

First Names:

Surname:

Maiden Name:

Previous Names:

Address:

Postcode:

Telephone Number:

Mobile Number:

NI Number:

Gender*:

*Only compulsory if required for the role

Email Address:

Are you a Driver:

Yes

No

Own Transport:

Yes

No

N/A

How long have you had a licence?

Any Endorsements:

Yes

No

N/A

Next of kin Name:

Tel:

Are you a United Kingdom (UK) National

Yes

No*

*If no, please detail your current immigration status and the relevant visa currently held (including Visa number)

Are you related to any of our current members of staff or Service Users?

Yes

No

Equality Act 2010 - Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a “substantial” and “long-term adverse effect” on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-under-equality-act-2010.

For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?

Education *(All qualifications will be subject to a satisfactory check).

School / College / University

Date From:

Date To:

Examinations, Qualifications*

Training Courses attended or completing (evidence of attending courses may be required)

Subject

Location

Date

Details

Professional Memberships / Registrations

Name of Organisation

Registration Number

Renewal Date

Details

Employment History

Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained.

Start Date:

End Date:

Salary:

Job Role:

Employer Name:

Reason for Leaving:

Contact Name:

Duties:

Address:

Postcode:

Telephone:

Email:

Explanation of Gaps

Use this section to detail any gaps in employment and why

References

Please provide names, addresses and telephone numbers for referees below whom we may approach for a reference. In line with CQC requirements, we require references (or other satisfactory evidence as the employer may determine) from all previous employers concerned with the provision of services relating to health or social care, or children or vulnerable adults which should include details of why their employment came to an end (note that this is not time limited). If your previous employment does not concern the provision of services relating to health or social care, or children or vulnerable adults, you must provide references from your two most recent employers.

Please provide two character references if you are unable to obtain two professional references, e.g. in the case of an applicant who has been raising children for ten years. All will be contacted. Therefore, please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.

Contact Name:

Business Name:

Address:

Postcode:

Telephone:

Email:

Capacity in which known:

Professional / Character:

Safeguarding / Ex-Offenders Declaration

Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest confidence.

The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. Kharis Health Care Ltd undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.

Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country?

Yes*

No

*If yes, please provide details:

Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country?

Yes*

No

*If yes, please provide details:

Privacy Statement

We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to us holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you). When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles.

We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the Day to day charge of the regulated services provided and only used for the purposes of recruiting for this vacant post.

You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Day to day charge of the regulated services provided to discuss.

Declaration

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that can seek clarification regarding professional registration details.

Print Full Name:

Signature (Put Initials):

Date:

Supporting Statement

Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe particular strengths and talents that set you apart from others as well as including skills gained from work, home and other activities.

Application Form - PR26

Application Form - PR26

Job Position Details

Personal Details

Education *(All qualifications will be subject to a satisfactory check).

Training Courses attended or completing (evidence of attending courses may be required)

Professional Memberships / Registrations

Employment History

Explanation of Gaps

References

Safeguarding / Ex-Offenders Declaration

Privacy Statement

Declaration

Supporting Statement

Useful Links

Address Us

CQC Rating

DKM Healthcare Application Form

Application Form - PR26

Application Form - PR26

Job Position Details

Personal Details

Education *(All qualifications will be subject to a satisfactory check).

Training Courses attended or completing (evidence of attending courses may be required)

Professional Memberships / Registrations

Employment History

Explanation of Gaps

References

Safeguarding / Ex-Offenders Declaration

Privacy Statement

Declaration

Supporting Statement

Useful Links

Address Us

CQC Rating