Admin Application

Admin Application Form (#5)

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ADMIN APPLICATION FORM
UK Applicant
International Applicant
Title
Other
Upload your CV
Choose File
First Name
Email address
Date of Birth
Last Name
National Insurance No.
Mobile Number
Marital Status
Address
Address Line 1
Address Line 2
City
County
Post Code
Country
Preferred Contact Method:
Email
Phone
Post
Text
Call expectancy
Morning
Night
Both
Various Information
Work Status
Do you require a Home Office letter to work?
Yes
No
Home Office Letter Ref:
Permit Type
Nationality
Do you require a work permit?
Yes
No
Work Permit
Expiration Date
Passport Number
Birth Certificate No.
Expiration Date:
Name of College / University (if student):
Have your own transport:
Yes
No
Type of Transport:
Do you have a driving license:
Yes
No
Any endorsement:
Religion:
Other:
Ethnic Origin:
Other
Children Under 18 Years?:
Yes
No
Child/Children First name and age
Registered Disabled
Yes
No
Registration No.
Do You smoke?
Yes
No
Give Details of Hobbies / Leisure Activities:
PROFESSIONAL EDUCATION & TRAINING
PLEASE LIST ANY TRAINING / COURSE / HEALTHCARE QUALIFICATION YOU HAVE AND WHEN YOU GAINED THEM
Qualification
School / College University
Dates
Qualification
School / College University
Dates
Qualification
School / College University
Dates
Qualification
School / College University
Dates
EMPLOYMENT HISTORY
PLEASE GIVE DETAILS OF YOUR PAST 5 YEARS OF CONTINUOUS WORK HISTORY GIVING REASONS/S FOR ANY BREAKS IN EMPLOYMENT.
Employer
Date From
Date To
Address
Address Line 1
Address Line 2
City
Post Code
Country
Phone/Mobile
Main Responsibilities:
Email
Reasons for leaving:
Employer
Date From
Date To
Address
Address Line 1
Address Line 2
City
Post Code
Country
Phone/Mobile
Main Responsibilities:
Email
Reasons for leaving:
Employer
Date From
Date To
Address
Address Line 1
Address Line 2
City
Post Code
Country
Phone/Mobile
Main Responsibilities:
Email
Reasons for leaving:
Please provide details if answered YES in the above
DO YOU OR HAVE YOU AT ANY TIME SUFFERED FROM ANY OF THE FOLLOWING?
YES NO
Skin Complaints- Dermatitis, Psoriasis, Eczema
Diabetes Or Glandular Complaints
Headaches Or Migraine
Hypertension/ Heart Problems/ Similar Illness
Back Pains / Back Injury Or Problems
Jaundice / Hepatitis
Epilepsy Or Fainting Attacks
Pleurisy /Bronchitis / Pneumonia
Asthma
Infections - Ear / Sore Throat
Psychiatric Illness - Mental Disorder/ Depression etc
Please provide details if answered YES in the above
AT PRESENT ARE YOU HAVING ANY INJECTIONS/MEDICATIONS
YES NO
Are you under any treatment of any kind of condition?
Have you had any major operations
Physical disabilities?
How much time have you taken off Work in the last 5 years due to illness?
Please state any other information about your health which may affect your work
Please provide details if answered YES in the above
IF YOU DO NOT HAVE VACCINATION INFORMATION , PLEASE PROVIDE DETAILS OF WHERE WE CAN REQUEST THEM BELOW.
GP / Occupational Health / Hospital
Address
Address Line 1
Address Line 2
City
Post Code
Country
Phone
Mobile
Email

I certify the above information is correct and hereby give permission to Perfect Quality Care to request a further report from my GP/ Occupational Health/ Hospital for clarification if required and for my health report. Privacy Policy
WORK PREFERENCES
PLEASE SPECIFY THE KIND OF CARE WORK YOU ARE INTERESTED IN? (TICK ALL THAT APPLY)
NHS
Private Hospital
Nursing Home
Residential Home
Short Term
Long Term
Others:
Others
PLEASE INDICATE WHEN YOU WOULD LIKE TO WORK. PLEASE TICK ALL RELEVANT BOXES.
Part-Time
Full-Time
Bank Holidays
Days (M-F)
Evenings (M-F)
Nights (M-F)
Days (Sat-Sun)
Evenings (Sat-Sun)
Nights (Sat-Sun)
From when are you available to work?:
Date available for interview?:
Do you have any holiday booked? If yes, when?
REHABILITATION OF OFFENDERS ACT 1974
Because of the nature of the work for which you are applying, this post is exempt from the provisions of section 4.2 Rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are therefore, not entitled to withhold information about convictions, which for other purposes are 'spent' under the provision of the Act in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Information provided will be kept confidential and use in relationship to the post applied for.
Have you ever been convicted of a criminal offence?
Yes
No
Please specify:
Do you have any spent or unspent convictions?
Yes
No
Please specify:

I consent to Perfect Quality Care checking the details I have provided against the various data sources in order to verify my identity and process this application. These details maybe use to assist other organisation such as DBS checks, in identity purposes.
REFERENCES
Please give the names and addresses of two of your most recent employers with work addresses who can comment on your work ability and experience. Starting with your present to most recent employer if possible.
1.
Company’s Name
Name of Reference:
Email
Phone/Mobile
Date From
Date To
Address
Address Line 1
Address Line 2
City
Post Code
Country
2.
Company’s Name
Name of Reference:
Email
Phone/Mobile
Date From
Date To
Address
Address Line 1
Address Line 2
City
Post Code
Country

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