Staff Application Form

All information will be treated as strictly confidential.

*PLEASE READ BEFORE COMPLETING*

All applicants must satisfy the UK government requirements to confirm your identity

(Please see the DBS document).

We also require that you supply the following:

· Any name change since birth.

· Any change of address in the last 5 years.

· All employment for the last 10 years including any breaks in employment.

· Please explain any breaks in your employment.

· You must supply a minimum of three references

IF YOU CANNOT SUPPLY THE REQUIRED INFORMATION

WE CANNOT EMPLOY YOU

Position applied for:

Surname:

First Forename:

Second Forename:

Address:

Post Code:

Home Telephone No:

Mobile Telephone No:

Maiden Name:

N.I Number

Work Permit No:

Emergency Contact Name & Number:

Relationship:

Address:

Post Code:

Home Telephone No:

Mobile Telephone No:

Where did you hear about this job opportunity? Please specify.

Name Changes (Since birth)

From:

To:

Date Changed:

From:

To:

Date Changed:

From:

To:

Date Changed:

Address Changes (Last 5 years)

Address:

From:

To:

Address:

From:

To:

Address:

From:

To:

Address:

From:

To:

Address:

From:

To:

Equal Opportunities

Napier Homecare Services Ltd is an Equal Opportunities employer. To assist us in monitoring the effectiveness of our policies, we would be grateful if you would provide the following information.

Registration No:

Please Give Details:

Employment History

Full Employment History with all gaps explained (Current or Most Recent Post First)

Current or most recent Employer:

Address:

Telephone No:

From:

To:

Position Held:

Description of Duties:

Previous Employment: Please explain any gaps

Name:

Address:

From:

To:

Name:

Address:

From:

To:

Name:

Address:

From:

To:

Name:

Address:

From:

To:

Name:

Address:

From:

To:

Name:

Address:

From:

To:

Name:

Address:

From:

To:

Name:

Address:

From:

To:

Name:

Address:

From:

To:

Name:

Address:

From:

To:

References of Employment

References

If you would prefer us not to contact your current employer for a reference prior to offering you the post applied for, you must give at least give one other former employer (the most recent) from which we can take up references:

Please Provide a Minimum of (3) Three References

Name:

Telephone No:

Occupation:

Address:

Post Code:

Name:

Telephone No:

Occupation:

Address:

Post Code:

Name:

Telephone No:

Occupation:

Address:

Post Code:

Development & Training History

Basic Training

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Specialised Training

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Subject

Qualification

Awarding Body

Year

Disciplinary History

Declaration to be completed by all persons applying for a position involving the delivery of a care services for Adults and Children. Any information given will be completely confidential and will be considered only in relation to an application.

If Yes - Please give details including dates, name and address of employer, type of employment and the reason for dismissal or request to resign:

Employer:

Address:

Date:

Comments:

If Yes - Please give details including dates, name and address of employer, type of employment and the reasons for the disciplinary action and the outcome:

Employer:

Address:

Date:

Comments:

Declaration of Criminal Record

As stated on the application form, because of the sensitive nature of the duties the post holder will be expected to undertake, you are required to disclose details of any criminal record. Only relevant convictions and other information will be taken into account so disclosure need not necessarily be a bar to obtaining this position.

Rehabilitation of Offenders Act 1974

(Exemptions Order 1975)

Because of the nature of the work for which you are applying, this post is exempt from the provisions of section 4(2) of the act. Applicants are therefore not entitled to withhold information about convictions which for the purposes are ‘spent’ under the provisions of the act.

Any information given will be completely confidential and will be considered only in relation to an application.

(Note that the post you have applied for is excepted from the Rehabilitation of Offenders Act 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need to be disclosed.)

If yes, please give details of offences, penalties and dates:

Health Declaration

Comments:

When did you last have the following immunisations?

Hepatitis:

TB:

Tetanus:

Flu:

Comments:

Napier Homecare Services Ltd, advocate immunisation of all staff against Hepatitis, Tuberculosis, Tetanus and Flu.

Declaration of Health

I declare that the above statements are true. I understand that the non-disclosure or suppression of any relevant facts known by me may prejudice my application, or if appointed could lead to the termination of my employment.

Your Signature

Select a date

Availability for Work

Please indicate the Times when you will be available to work

Monday

AM:

PM:

Evenings:

Nights:

Tuesday

AM:

PM:

Evenings:

Nights:

Wednesday

AM:

PM:

Evenings:

Nights:

Thursday

AM:

PM:

Evenings:

Nights:

Friday

AM:

PM:

Evenings:

Nights:

Saturday

AM:

PM:

Evenings:

Nights:

Sunday

AM:

PM:

Evenings:

Nights:

Other:

Preferred Days off:

Preferred Evenings off:

Weekends off:

None:

1 in 2:

1 in 3:

1 in 4:

Please indicate the type of work you are interested in doing

Comments:

Stakeholder Pension

Napier Homecare Services Ltd affords access to a Stakeholder Pension to enable you to consider your own personal pension arrangements.

Comments:

Your Signature

Select a date

Thanks for submitting!

D.B.S. Disclosure

I agree to refund the cost of the D.B.S. if my probationary period of three months is not completed.

Declaration

I confirm that the information I have given on this application form is correct and complete, and that misleading statements may be sufficient for rejecting my application and any agreements made.

I also understand that the declaration will include details of any criminal convictions, cautions, reprimands and final warnings and any other information that may have a bearing on my suitability for the post. I understand that an Enhanced Disclosure will be sought in the event of a successful application.

Disclosure and Barring Service (DBS) application ID Check Documents

As a part of your DBS application we will need to confirm your identity.

You need to provide original documentation (photocopies are not accepted) to the Admissions Office at one of our drop in sessions:

What documents do you need to provide?

You must provide 3 documents:

1 document from Group 1 and 2 further documents from Group 1, 2a or 2b, one of which must confirm your current address.

Document Group 1 Primary Trusted Identity Documents

A current Valid Passport (any nationality)
Biometric Residence Permit (UK)
A current photocard driving licence with its counterpart (where issued)
An Original BRITISH Birth Certificate (UK) - issued within 12 months of the date of birth
Adoption Certificate (UK)

Document Group 2A Trusted Government/State issued documents

Birth certificate (UK) issued more than 12 months after birth
Marriage / Civil partnership Certificate (UK)
A current Driving Licence (UK, full or provisional), including old style paper version (UK)
A current photocard driving licence that was issued with a counterpart
Firearms Licence (UK)
HM Forces ID card (UK)

Document Group 2B Financial/Social History documents

The following documents must be less than 3 months old:

Credit Card Statement (UK)
Bank / Building Society Statement (UK)
Utility Bill / Statement: electricity / gas / water / telephone (NOT mobile telephone)
Benefits Statement e.g. Child Allowance, pension
A document from Central / Local Government / Government Agency / Local Authority giving entitlement (UK and Channel Islands) e.g. from the Department of Work & Pensions, the Employment Service, Customs & Revenue, Job Centre, Job Centre Plus, Social Security. This includes National Insurance Number issue letter.
Bank / Building Society Account Opening Confirmation Letter (UK)

The following documents must have been issued within the past 12 months:

Mortgage Statement (UK)
Financial Statement e.g. pension, endowment, ISA (UK)
P45 / P60 statement (UK)
Council Tax Statement (UK)
Work Permit / VISA (UK), (UK Residence Permit)

The following documents must still be valid:

EU National ID card
Cards carrying the PASS accreditation logo (UK)