Position Applied For *Location: *Work Preference: *WorkPreferenceFull TimePart TimeBankHours RequestedPersonal DetailsFirst Name *Address *0 / 180Last name *Maiden Name *Previous Names *Marital Status *MaritalStatusMarriedSingleDivorcedWidowedPrefer Not to SayGender *GenderMaleFemalePostcode *Place of Birth *Nationality *NationalityUnited KingdomAngloaUnited States of AmericaTelephone Number *NI NumberMobile Number: *Email Address *Are you a Driver *YesNoHow long have you had a licence? *Any Endorsements: *YesNoN/A*Are you a United Kingdom (UK) National? *YESNO*If no, please detail your current immigration status and the relevant visa currently held (including Visa number)Are you exempt from the English language requirement? (If No, please complete the question below) *YesNoHave you passed your English test?YesNoResults (Please write your scores)ReadingWritingSpeakingOverall Band ScoreAre you related to any of our current members of staff or Service Users? *YesNoHTMLEquality Act 2010 - Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a “substantial” and “long-term adverse effect” on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-under-equality-act- 2010.For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?YesNoPrefer not to sayImmunizationHTMLIt is very important that Care /Support Workers (CSWs) are aware of the importance of immunization. This is in order to provide safeguards for the Service User, the CSW and their families. With regards to this it is particularly important that vaccination against the following is advisable to be obtained and frequently maintained. However, this is not an employment requirement rather it is introduced on advisory basis:PollioTBTetanusRubella / Mumps / MeaslesDiphtheriaHepatitis BDo you have evidence of TB Test? *YesNoDo you have evidence of Hepatitis B Test? *YesNoEducation *(All qualifications will be subject to a satisfactory check)EducationSchool / College / UniversityDate FromDate ToExaminations, Qualifications*Add itemRemove itemTraining Courses attended or completing (evidence of attending courses is required)SubjectLocationDateDetailsAdd itemRemove itemProfessional Memberships / RegistrationsName of OrganisationRegistration NumberRenewal DateDetailsAdd itemRemove itemEmployment HistoryEmployment HistoryHTMLPlease record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained.Start DateEnd DateSalaryJob RoleEmployer NameReason for LeavingContact NameDutiesAddressPostcodeTelephoneEmailExplanation of Gaps Use this section to detail any gaps in employment and whyReferencesHTMLPlease provide names, addresses and telephone numbers for referees below who we may approach for a reference. In line with CQC requirements, we require references (or other satisfactory evidence as the employer may determine) from all previous employers concerned with the provision of services relating to health or social care, or children or vulnerable adults which should include details of why their employment came to an end (note that this is not time limited).If your previous employment does not concern the provision of services relating to health or social care, or children or vulnerable adults, you must provide references from your two most recent employers.Please provide two-character references if you are unable to obtain two professional references, e.g. in the case of an applicant who has been raising children for ten years. All will be contacted. Therefore, please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.HTMLWork reference — not members of your own familyContact NameBusiness NameAddressPostcodeTelephoneEmailCapacity in which knownCharacter ReferenceContact NameAddressPostcodeTelephoneEmailProfessional / CharacterCapacity in which knownSafeguarding / Ex-Offenders Declaration:HTMLThe Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. Medicare Support and Housing LTD undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.Do you have a criminal records certificate/ Certificate of good conduct (Police Check from your country residence) *YesNoAre you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country? *YesNoDo you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country? *YesNoPrivacy StatementHTMLWe will only collect data for specified explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to us holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you). When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles.We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant post.You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Registered Manager to discuss.DeclarationHTMLThe information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that can seek clarification regarding professional registration details.PrefixMr.Mrs.Ms.Mx.MissDr.Prof.First NameMiddle NameLast NameUpload Signature *Choose FileNo file chosenDelete uploaded fileApplication Date *Supporting StatementPlease add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe particular strengths and talents that set you apart from others as well as including skills gained from work, home and other activities.Committed to Equality of Opportunity and Fair TreatmentHTMLMedicare Support and Housing LTD is committed to equality of opportunity and fair treatment in all aspects ofemployment. We aim to provide a working and learning environment which is free from unfair discrimination and will enable staff to fulfil their personal potential. The Equality Act 2010 protects people from discrimination and promotes equality on the basis of a number of ‘protected characteristics’. We ask for information on your ‘protected characteristics’ in order to help us monitor our performance on equality. In line with Government policy, and in accordance with the provisions of GDPR, the information you provide will be held confidentially and It will help us to comply with the law under the relevant Acts and to ensure that our employment policies and practices are fair and effective.IMPORTANT - Please Note: You do not have to complete this form. The information is given on a voluntary basis and the information provided will only be used for the monitoring purpose. Please do not enter any identifying marks on this form, so that your information remains confidential. This information will be stored on a computer.Ethnic Origin: Please indicate your Ethnic OriginEthnic Origin: Please indicate your Ethnic OriginAsian or Asian BritishMixedBlack or Black BritishWhiteI do not wish to disclose my EthnicGender: Please indicate your GenderGender: Please indicate your GenderFemaleMaleTransgender FemaleTransgender MaleOtherI do not wish to disclose my genderSexual Orientation: Please indicate your Sexual OrientationSexual Orientation: Please indicate your Sexual OrientationHeterosexualBisexualGayLesbianOtherI do not wish to disclose my Sexual OrientationReligion or Belief: Please indicate your Religion or BeliefReligion or Belief: Please indicate your Religion or BeliefBuddhistJewishChristianMuslimSikhI do not have any Religion or BeliefsI do not wish to disclose my Religion or BeliefOtherMarital Status: Please indicate your Marital StatusMarital Status: Please indicate your Marital StatusCommon Law PartnershipMarried / Civil PartnershipWidowedDivorcedSingleOther (State)As per Equality Act 2010: Do you consider yourself to have a disabilityAs per Equality Act 2010: Do you consider yourself to have a disabilityYesNoI do not wish to disclose whether or not I have a disabilityUnder the terms of the Act, a disability is defined as a “physical or mental impairment which has a substantial and long- term effect on a person’s ability to carry out day-to-day activities”.Caring Responsibilities: Do you have any care responsibilities for anyoneCaring Responsibilities: Do you have any care responsibilities for anyoneYesNoIf yesIf yesChildren U16DisabledSick / ElderlySend Message