APPLICATION FOR EMPLOYMENT FORM      C4-006

Hasbury and Rosemary Lodge Care Homes

Job applied for : 

Date:	

Please return form to:   Manager, Hasbury Care Home, 154 Middleton Hall Road, 
 Kings Norton, Birmingham B30 1DN    Tel: 0121-458-5336   Fax: 0121-243-5336

We are committed to promoting the equality of opportunity and welcome applications from anyone 
who feels that they are able to carry out the duties, regardless of any previous experience.

Please tell us about yourself

Surname: 	

First name: ……………………………………… Other names: …………………………….	

Home address: 	..................

		
Postcode:		

NI mumber: ……………………………………	
Date of birth:  ………………	

Home tel. no: 	.	
Work tel. no: .............................................	
 May we ring you at work?   YES / NO
	Are you related to any present or former employees of the home?            YES / NO	
How did you find out about this vacancy?

Please give us the details of two people who will provide us with a reference. One should normally be your current employer.  If this is not the case, please tell us why not. We will not contact your employer before an interview, but we will contact them before appointment.

Name: 	
Position: 	
Organisation: 	
Address: 	
Postcode: 	
Tel. no. work:	
Tel. no. other: 	
Is this your current employer?   YES / NO
Are they related to you?             YES / NO	
Name: 	
Position: 	
Organisation: 	
Address: 	
	
Postcode: .	
Tel. no. work: 	
Tel. no. other: 	
Is this your current employer?   YES / NO
Are they related to you?         YES / NO	

Please tell us about your education and training 
Please tell us about your education.  List any qualifications gained.

School / College	From	To	Qualifications – 
include dates and grades	

				

If you have undertaken any training or voluntary work to improve your employment prospects, please give details below:	

	

Please tell us about jobs you have had
Please tell us about the jobs you have had in the past ten years starting with your present, or most recent, job first.  If there are gaps in employment please tell us why e.g. unemployment, bringing up family etc.	

Employer	Job title and description of duties	Salary / wages 	From	To	Reason for leaving	

	

					

Further information
Please use this space to tell us about any other information that you feel will help your application, including any other skills you may have.  Please feel free to continue on a separate sheet of paper if required.

	

Do you hold a current, clean driving licence: 				YES / NO

Declaration of Convictions / Disclosure of Information

Successful applicants will be asked to provide disclosure information as required under section 113 of the Police Act 1997.

Disclosure information will not be used unfairly and a criminal record will not necessarily be
a bar to obtaining the position applied for.

No offer of employment will be withdrawn without discussion with the applicant.

Note that false declarations may be reported to the police.
…………………………………………………………………………………………………..
Health Questionnaire

Please complete the attached Health Questionnaire.

I certify that the information given in this application is true and accurate to the best of my knowledge.  I also understand that if I am appointed and information is subsequently found to be false, I might be dismissed.

Signed: ……………………………………………..            Date: ………………….………

Data Protection Information
The information which you have supplied on this form will be processed and may be held on computer, and will be held on your personal records file if you are appointed.
The information will also be used for equality monitoring and statistical purposes.  By signing this application, you will be deemed to have given your consent to this, including information which may be considered to be sensitive and personal.	

Health Questionnaire

Regulation 19 (5) of the Care Homes Regulations 2001 requires that all employees who work in care homes are both physically and mentally fit to undertake their duties.  

Please answer the following questions:

1. 	How many days were you absent from work due to sickness in the last year? 	No. of 
Days:  ........	
2. 	Have you ever suffered from:  
Allergies, eczema, dermatitis or other skin troubles?	YES / NO	
3. 	Do you suffer from: 
Epilepsy, migraine, asthma, angina, heart trouble or any condition requiring long-term medical help or a strict medication  timetable?	YES / NO	
4. 	Have you ever suffered from:
Mental illness including anxiety, depression or nervous debility?	YES / NO	
5. 	Have you ever required treatment for:
Hernia or rupture, rheumatism, back problems, slipped disc, sciatica or Repetitive Strain Injury (RSI)?	YES / NO	
6.	Do you suffer from: 
Diabetes, ulcers, stomach or other intestinal disorders?	YES / NO	

If you have answered yes to any of the questions above, please provide further details below.

	

	

Declaration:
I hereby confirm that I know of no reason, in relation to either my physical or mental health, why I would be unable to undertake the duties required for the post applied for.

Signed: …………………………………………..                  Date: ….......……………..