- Step 1 of 4Personal detailsTitlePlease SelectMissMrsMsMrName *FirstLastOther names by which you are knownDate of BirthMarital StatusPlease selectMarriedUnmarriedDivorcedPermanent Address in UK: House NumberStreetTown/CityPostcodeContact detailsTelephone (Mobile)Telephone (Home)Email *NationalityNational Insurance NoIf not british, please state visa statusAre you allowed to work in the UK?YesNoLanguages spoken excluding EnglishNext of KINKIN RelationshipKIN NameKIN AddressKIN Telephone(mob)KIN HomePlease specify your availability by highlighting your choiceMonTueWedThuFriSatSunMon (Work Hours AM/PM)Tue (Work Hours AM/PM)Wed (Work Hours AM/PM)Thu (Work Hours AM/PM)Fri (Work Hours AM/PM)Sat (Work Hours AM/PM)Sun (Work Hours AM/PM)Are you interested in any of the following jobs?Live InSit InWake InSleep inNextReference and employment history Please indicate your experience by ticking the appropriate boxesIncontinence ManagementManaging People with Terminal IllnessManagement of AggressionManaging People with AIDS/HIVManging People with Challenging, Anti-Social BehaviourManaging People with Sensory Loss & ImpairmentManging People with Learning Difficulties Managing Physical Disabilities Managing People with DepressionManaging People with Mental Health Problems Inc. DementiaManaging Specialist Lifting, Handling Techniques Managing People with Alcohol, Drug misuse Employer's NameAddressPosition You HeldDuration of Employment From:Duration of Employment To:Salary £/Per Annum20,000 - 30,00030,000 - 40,00040,000 - 50,00050,000 - 60,00060,000 - 70,00070,000 - 80,00080,000 - 90,00090,000 - 100,000100,000 - 110,000Reason for LeavingDuties and responsibilitiesDo you have any disabilities or illness that will prevent you from working if yes please write information belowYesNoIf yes then please give us details...ReferencesReferee 1:TitlePlease SelectMissMrsMsMrNamePositionOrganisationAddressEmailReferee 2:TitlePlease SelectMissMrsMsMrNamePositionOrganisationAddressEmailHOME OFFICE CIRCULAR HOC 102/ 88 ALL APPLICANTS MUST ANSWER ALL QUESTIONS ON THIS FORM. FAILURE TO DO SO WILL INVALIDATE YOUR APPLICATION. In accordance with the above circular, you are required to provide the following information which will be passed on to the police authorities to check the existence and content of any criminal records. Because of the nature of the work, jobs and assignments are exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986. Applicants are, therefore, not entitled to withhold information about convictions, reprimands or final warnings which, for other purposes, are ‘spent’ under the provision of the Act and in the event of employment any failure to disclose such convictions could result in removal from Aphek home Care’s list of employees. Please note that this information will only be provided to and checked with the police authorities after a recruitment interview has taken place.PreviousNextFurther education and trainingQualification obtained / expectedOrganising bodyDate From (dd/mm/yyyy)Date To (dd/mm/yyyy)Work historyRecord From age 16 to PresentEmployer's NameAddressPosition You HeldDuration of Employment From:Duration of Employment To: Salary £/Per Annum20,000 - 30,00030,000 - 40,00040,000 - 50,00050,000- 60,00060,000 - 70,00070,000 - 80,00080,000 - 90,00090,000 - 100,000100,000 - 110,000Reason for LeavingDuties and responsibilitiesEmployer's NameAddressPosition You HeldDuration of Employment From:Duration of Employment To:Salary £/Per Annum20,000 - 30,00030,000 - 40,00040,000 - 50,00050,000 - 60,00060,000 - 70,00070,000 - 80,00080,000 - 90,00090,000 - 100,000100,000 - 110,000Reason for LeavingDuties and responsibilitiesPreviousNextEqual opportunities policy – monitoring checklistFor the purpose of monitoring our Equal Opportunities policy as stated above, please complete the followingGenderPlease SelectMaleFemaleRacial OriginAsianBlackWhiteNational OriginPakistaniAfricanBritishBangladeshiCaribbianEuropeanIndianOtherDo you consider yourself as having a disability that could affect your day to day work?YesNoIf yes, please give us details...Have you ever been convicted of a criminal offence, cautioned, sentenced, reprimanded or given a final warning by the police?YesNoIf yes, please give us details...Full NamePresent addressI have lived at the above address sincePrevious address: (must cover the previous 5 years)Date of BirthUniform sizePlease selectXSSLXLYour maiden nameColour of your eyes (e.g Brown)Height (e.g 5 Feet, 12)I consent to the following information being checked with the police and I am aware that any ‘spent’ convictions will be disclosed.SignedClear SignatureDatePreviousEmailSubmit
