UK Application Form Post applied forSenior Care WorkerCare AssistantHome Care OrganiserService ManagerAssistant Service ManagerFull name *GenderMaleFemalePrefer not to sayOtherHome Address *Post code *Home Telephone *Daytime Contact Number *Email Address *National Insurance Number *Date of Birth *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Are you free to remain and take up employment in the UK?..........YesNoDo you have a visa or residence permit?..........YesNoType of Visa? *Expiry Date *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Present Nationality *Do you have any restrictions?..........YesNoCurrent Driving Licence? *..........YesNoAccess to a car?..........YesNoCurrent EmploymentName of your most recent/current employer *Address of employer *Date *Nature of business *Position Held *Reasons for leaving *Employment HistoryName and address of previous employer *Date *Nature of Business *Position held and main duties *Reasons for leaving *Qualifications and TrainingName of InstitutionCourseQualificationDate completedName of InstitutionCourseQualificationDate completedAssistance with interview questionsDo you require us to make any special arrangements in order for you to participate in the recruitment process? For example, large print forms? Or additional time to complete forms? *Please select an optionYesNoIf yes, please give detailsEmployment ReferencesPlease provide at least two employment references, one which must be from your current or most recent employer and one from previous employer.1. Referee Full name *Position *Company Name *Telephone number *Email Address *Full company address *2. Referee Full name *Position *Company Name *Telephone number *Email Address *Full company address *Regulatory Body RegistrationAre you currently registered with SSSC? *Please select an optionYesNoSSSC NumberAre you a member of the Protection of Vulnerable Groups Scheme (PVG) with Disclosure Scotland? *Please select an optionYesNoPVG Membership NumberRegulated to work with *Please select an optionChildrenProtected AdultsBothDeclaration of CriminalREHABILITATION OF OFFENDERS ACT 1974 (EXCEPTIONS AND EXLUSIONS (SCOTLAND) ORDER 2003. You are not entitled to withhold information about convictions which for other purposes are spent under the provisions of the Act and in the event of employment any failure to disclose such convictions could result in dismissal.Have you ever been convicted of a criminal offence or cautioned, or are you at present subject of criminal charges or proceedings? *Please select an optionYesNoIf you have answered yes please give details:Date of ConvictionNature of OffencePenalty/SentenceDate of ConvictionNature of OffencePernalty/SentenceSignature And DeclarationI declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached, and my employment will be terminated immediately. I understand that I may not be offered a post until satisfactory response has been received with respect to my PVG register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references. By my signature, I authorise Baal-Perazim Care Services to request PVG background check. I undertake to inform my employer immediately of any change to my PVG, such as being charged with an offence, referral to any register of barred list, or withdrawal of any registration required by my employment status.Full name *Signature *Date *Consent *Yes, I agree with the privacy policy and Service User Privacy Statement. Send Message