Questions? Email us at careers@perfectqualitycare.co.uk

CARER 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 have a Home Office Letter

Yes

No

Home Office Letter Ref:

Permit Type

Nationality

Do you have a work permit

Yes

No

Work Permit

Expiration Date

Passport Number

Birth Certificate No.

Passport Country

Passport 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

Please type in what experience you have to work within care and how many years of experience do you have

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:

HEALTH DECLARATION

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

Others

Please state if you would like full time or part time?

Part-Time

Full-Time

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

Address

Address Line 1

Address Line 2

City

Post Code

Country

2.

Company’s Name

Name of Reference:

Email

Phone/Mobile

Address

Address Line 1

Address Line 2

City

Post Code

Country

Work in care.
Introduce yourself.

Good care starts
with how you treat people.

Respect and empathy

Reliability and teamwork

A willingness to learn

CARER APPLICATION FORM

Various Information

PROFESSIONAL EDUCATION & TRAINING

EMPLOYMENT HISTORY

HEALTH DECLARATION

WORK PREFERENCES

REHABILITATION OF OFFENDERS ACT 1974

REFERENCES

1.

2.

Work in care.Introduce yourself.

Good care startswith how you treat people.

Respect and empathy

Reliability and teamwork

A willingness to learn

CARER APPLICATION FORM

Various Information

PROFESSIONAL EDUCATION & TRAINING

EMPLOYMENT HISTORY

HEALTH DECLARATION

WORK PREFERENCES

REHABILITATION OF OFFENDERS ACT 1974

REFERENCES

1.

2.

Work in care.
Introduce yourself.

Good care starts
with how you treat people.