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Home
About
Services
Our Carers
How We Work
Join us
Jobs
Contact us

1Your Personal Details

2Employment & Education

3Skills & Training

4Declaration & Terms

Company

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Elizabeth's Rose Home Care

Post Applying for:

Personal Details 1

Name(Required)

Title First Name Middle Name Last Name

Home Phone

Mobile No(Required)

Email(Required)

Date of birth(Required)

DD slash MM slash YYYY

National Insurance No:

Address

Your Current Address(Required)

Street Address City County / State / Region ZIP / Postal Code

Personal Details 2

Marital Status(Required)

Nationality(Required)

Gender

Religion

Race/Ethnicity

Sexual Orientation(Required)

Employment Eligibility

Are you permitted to work in the #~Region~#?(Required)

Yes

No

Can you provide evidence to prove eligibility?:(Required)

Yes

No

Please select document you can provide

Provide name of document you can use

What visa/permit/status do you currently hold?:

Working Holiday

Work Permit

Leave to Remain

Other

Please state what visa/permit you hold:

Permit/Document No:

Passport No:

Visa/Permit Expiry Date:

YYYY dash MM dash DD

If it has no expiry please put a day 10 years from today.

Driving Details

Do you have full Driving Licence that allows you to drive in the UK?(Required)

Yes

No

Driving Licence No:

Do you have access to a car that you can use for work?(Required)

Yes

No

Have you been banned from driving or do you have any current endorsements on you licence?(Required)

Yes

No

Are all your vehicle documents up to date and valid?(Required)

Yes

No

How would you travel to work if assigned?(Required)

Next of kin details

Full Name(Required)

Prefix First Last

Relationship to you:(Required)

Home/Work Phone

Mobile No(Required)

Email

Address(Required)

Street Address City County / State / Region ZIP / Postal Code

Your Work Preference

When are you able to work?(Required)

Mornings

Evenings

Afternoons

Full Time

Part Time

Weekends

Anytime

EDUCATION & EMPLOYMENT HISTORY

Please ensure you complete this section even if you have a CV. The NHS states that “Employment history should be recorded on an Application Form which is signed” Please ensure that you leave no gaps unaccounted for and it covers full work history including your education. Please use extra paper if required.

Full work history including your education
Dates to and from are shown in a mm/yy format
Dates are continual with NO gaps
Where there have been gaps in work history please state the reason for the gaps
Lists all relevant training undertaken

Employment History(Required)

Please Include any gaps in employment.

Employer

Position

Duties

Date From - To

Reason for leaving

Education

Please supply documentary evidence.

Education(Required)

Institution

Course

Year

Grade

Upload CV if you have one.

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 128 MB.

REFERENCES

Please supply us with two professional referees. One must be from your present or most recent employer and must be a senior grade to yourself and you must have worked for that person for a period of not less than three months duration.

Reference 1

Relationship(Required)

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Address(Required)

Street Address City County / State / Region ZIP / Postal Code

Reference 2

Relationship(Required)

Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address City County / State / Region ZIP / Postal Code

SKILLS, EXPERIENCE & TRAINING

Have you completed mandatory training within the last year?(Required)

Yes

No

Other Training/Courses & Qualifications

Please check which training you have completed and the date on the notes (certificates must be provided).

Diploma in Health & Social Care L3

Diploma in Health & Social Care L2

Personal Safety (Mental Health & Learning Disability)

Intermediate Life Support

Advanced Life Support

Complaints Handling

Handling Violence and Aggression

DOLLS & Mental Capacity

COSHH

Data Protection

Equality & Inclusion

Lone Worker Training

Resuscitation of the Newborn (Midwifery)

Interpretation of Cardiotocograph Traces (Midwifery)

Training Dates

Please add dates of training.

APRAISALS

In order to work in the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser” Please give details below of the Senior Practitioner who you have made arrangements with to act as your appraiser.

Please give the date of your last appraisal(Required)

DD slash MM slash YYYY

Name of Appraiser(Required)

First Last

Position and Grade of Appraiser:(Required)

Branch Address:(Required)

Street Address City County / State / Region ZIP / Postal Code

Phone(Required)

Fax

Email(Required)

Enter Email Confirm Email

YOUR DBS STATUS & UNIFORM

Uniform

Your Tunic Size(Required)

Your Tunic Size(Required)

DBS Status

Please send a copy of your most recent DBS Disclosure (formally known as CRB)

Do you have a current DBS (Disclosure Barring Service) (formally known as CRB)?(Required)

Yes

No

Current DBS Disclosure (formally known as CRB)

Clear(Required)

Yes

No

Date of issue:(Required)

DD slash MM slash YYYY

Disclosure number

Is your current DBS on the annual update service?

All applicants who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost. The company will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate.

DECLARATIONS

Disclosure Barring Service (DBS)

The Disclosure and Barring Service (DBS – formerly Criminal Records Bureau CRB) is the executive agency of the Home Office responsible for conducting checks on criminal records. We are registered body for receipt of DBS disclosure information. NHS Trust and Private Sector hospitals and nursing homes insist on agencies making information recruitment decisions which require DBS checks to be made on all staff. It is a condition of proceeding with your application that you apply for a DBS disclosure check. The disclosure will be compared with the information given below and any inconsistencies could invalidate your application or lead to the cancellation of your registration with us.

Have you been convicted of a criminal offence?(Required)

Yes

No

Have you ever been cautioned or issued with a formal warning for a criminal offence?(Required)

Yes

No

If you have answered ‘yes’ to either of the above questions please list details including dates below

(Required)

I confirm the above is true and I understand that a DBS check will be sort in the event of a successful application.

Rehabilitation of Offenders Act 1974 and Criminal Records

By the virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986 the provision of section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such a kind to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties. You should there force list all offences below even if you believe them to be ‘spent’ or ‘out of date’ for some other reason.

Right To Work

It is a legal requirement that before any offer of work can be made all candidates provide the company with confirmation of their eligibility to work in the UK by providing one of the original documents detailed below.

A passport which describes the holder as a British Citizen or as having a right of abode in the #~Region~# or a passport or other travel document to show that the holder has Indefinite leave to remain in the #~Region~# and is not precluded from taking the work in question.

A passport or identity card issued by a State which is party to the European Union and EEA Agreement and which describes the holder as a national or a state which is a arty to that agreement.

A letter issued by the Home Office or the Department of Education and Employment indicating that the person named in the letter has permission to take agency work in question or a biometric residence permit.

Work Time Directives

It is a legal requirement that before any offer of work can be made all candidates provide the company with confirmation of their eligibility to work in the UK by providing one of the original documents detailed below.

(Required)

I DO NOT wish to work more than 48 hours per week

I DO wish to work more than 48 hours per week

Registration form Declaration

I declare that all information given in this registration form is to the best of my knowledge complete and accurate in all respects and that I am eligible to work in the UK. I understand that any false or misleading information may result in my removal from the register of members.

Today's Date(Required)

DD slash MM slash YYYY

Full Name:(Required)

Signature

Privacy(Required)

By using this form you agree with the storage and handling of your data by this website as defined in our Privacy Policy *

Office Address

Ground floor 6 Kings Row

Armstrong Road

Maidstone

ME15 6AQ

Contact Information

01622 296 224
info@elizabethsrose.co.uk
recruitment@elizabethsrose.co.uk

Opening Hours

Mon-Fri: 9:00am – 5:00pm
Saturday: Closed
Sunday: Closed

Copyright 2020 © Elizabeth's Rose Home Care Limited, Registered in England & Wales, Company Reg: 12833896.

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