APPLICATION FORM

Address

BLOSSOM BRIDGE HEALTHCARE SOLUTIONS LTD

James House

Albrighton

WV7 3FA

The recruitment process for the organisation has a minimum of two stages.

The completion of this application form is part of stage one. This application will be reviewed, and a decision made as to whether the process of stage two, the interview, based on this information.

PLEASE COMPLETE FULLY IN CAPITALS

Position Applied For:
Approx. Number of Hours Wanted:	Email:
Full-Time / Part- Time (Please circle which you want)
Surname:	First name(s):
Previous Surnames (supply documentary evidence e.g. Marriage certificate, deed of name change etc.)
Current Address:
Postcode:	Moved to this address on (date):
Previous Address Note: For Criminal Records check purposes, addresses covering the five years up to the applicants date must be supplied. If necessary, use another sheet of paper.
Postcode:	Moved to this address on (date):
Telephone Number (home):	Telephone Number (work- will be used with discretion):
Own Transport (YES / NO): How long has you licence been held?	Clean current driving licence: Endorsements:
Details:

NEXT OF KIN

Full Name:
Relationship:
Tel no:
Address

IDENTITY DETAILS

National Insurance Number: Bank account Sort code: Account number: Date of Birth: Mother’s Maiden Name: County of Birth: NMC Pin:

CAPACITY TO WORK IN THE UK

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?	No (Circle Appropriate)
If yes please provide details.
If you are successful in the application, would you require a work permit prior to taking up employment?	Yes / No (Circle Appropriate)

NOTE: Minimum Age legislation dictates that care workers in general must be 16 years old or older.

Please inform your interviewer immediately if you do not meet these specifications.

EDUCATION

School/ College/ University	Examinations Passed/ Qualifications Gained
(Please supply copies of certificates)

TRAINING HISTORY/PROFESSIONAL STATUS you must include all up to date relevant certificates you hold and the date you obtained them. Proof will be required.

Date of Graduation/ Qualification	Location/ Details	Notes
(please supply copies of certificates/ membership details)

SHORT COURSES ATTENDED

Subjects	location

EMPLOYMENT HISTORY

Current/most recent first. Information must cover the whole of your working life to date. State the reasons for any breaks in employment. Use a separate attached sheet if required. Please sign that sheet(s).

Name and Address of your most recent/last employer:
Dates employed (from and until)
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Name and address of employer prior to the employer listed above:
Date employed:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Name and address of employer prior to the employer listed above:
Date employed:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Other roles (Use Additional Sheet):

PLEASE PROVIDE AN UP TO DATE CURRICULUM VITAE WITH YOUR APPLICATION.

REFEREES

You must provide references from your two most recent employers. Please provide an additional character referee. 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.

CURRENT OR MOST RECENT EMPLOYER

Name:
Address:
Postcode:
Tel No:
Job Title:

PREVIOUS EMPLOYER TO THE ONE ABOVE

Name:
Address:
Postcode:
Tel No:
Job Title:

CHARACTER REFERENCE

Name:
Address:
Postcode:
Tel No:
Job Title:

EMPLOYMENT CONTINUITY CHECK

It is essential to check the continuity of employment, as stated in the application form and note and investigate any gaps in employment. Failure to carry through such checks has been identified as a significant factor in several recent abuse cases.

Use this ‘Timeline’ below to place in order all the stated instances of employment and other activities (such as training), and identify any gaps for discussion during the interview. Assess and record the results of the enquiries, which must be followed through if an interview answers are unsatisfactory. The period considered must be the whole working life of employment of the applicant, to date.

Example:

ASSISTANCE WITH INTERVIEW AND ASSESSMENT

Do you require us to make any special arrangements in order for you to participate in the recruitment process? For example, Large print forms? Or additionally time to complete forms? Yes / No
If yes, please give details:
Any offer of employment may be made subject to a satisfactory medical report.
GP’s Name:
Tel No:
Address:

CRIMINAL RECORD

Workers of the agency are subjected to the Health and Social Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether processed with or not, and warnings and cautions.

You will not be eligible for work in a care setting if you are on the DBS Register(s).

Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.
SIGNATURE and DECLARATION -IMPORTANT –READ BEFORE SIGNING
I declare to the best of my knowledge and believe the information given to 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 may be terminated immediately. I understand that I cannot be offered a post until a satisfactory response has been received with respect to my DBS register status, and that I should subsequently should be offered a post, that offer will be a subject to receipt of two satisfactory references, one of which must be from my previous employer, and that conformation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that the satisfactory response is received from the DSB, and the employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. By my signature I authorise the organisation to request a DBS register check and a criminal records check from the DSB, on initial employment and at any time during my employment thereafter, I undertake to inform my employer immediately if my DBS register status changes.
SIGNATURE:

PLEASE RETURN COMPLETED APPLICATIONS VIA EMAIL TO recruitment@blossombridge.co.uk