Apply - Pam-Eagle Health Care

Position Applied For: *

Date of Application

1. PERSONAL DETAILS

Surname *

First Name *

Previous Name

Street Address

ZIP / Postal Code

Home Telephone No.

Work Telephone No.

Mobile No.

National Insurance Number

Immigration Details

Are you a citizen of the EU?YesNo

Do you need a work permit?YesNo

Current driving license?YesNo

Do you have a car for work use?YesNo

2. EDUCATION

2. EDUCATION

Schools/FE/HE attended

Examination Grade

Year Obtained

3. PREVIOUS EMPLOYMENT

3. PREVIOUS EMPLOYMENT

A full employment history must be detailed beginning with your current employment and covering all reasons for gaps in any given year.

From

Employer’s name (most recent first)

Position held

Salary & Benefits

Reason for leaving

From

Employer’s name (most recent first)

Position held

Salary & Benefits

Reason for leaving

From

Employer’s name (most recent first)

Position held

Salary & Benefits

Reason for leaving

4a Please detail any disciplinary action within the previous 3 years, including any current, “live” formal warnings

4b REHABILITATION OF OFFENDERS ACT 1974 – NOTICE TO OFFENDERS

4b REHABILITATION OF OFFENDERS ACT 1974 – NOTICE TO OFFENDERS

1.Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)

2.The amendments to the Exceptions Order 1975 (2013) provide that certain convictions and cautions are protected and are not subject to disclosure to employers and cannot be taken into account

Do you have any convictions to disclose?YesNo

Any information should be given on a separate sheet and sent with this application form. This information will be treated as confidential and will not necessarily preclude you from employment.

Confirm the above information is correct. *Check

Date *

Failure to declare or the falsification of any of the above details will result in the withdrawal of any job offer.

5. ADDITIONAL PERSONAL DETAILS

5. ADDITIONAL PERSONAL DETAILS

Statement of your personal qualities and any experiences which is relevant to the post

6. REFERENCES

6. REFERENCES

Please give the name and address of two referees, one of whom must be your current or most recent previous employer. References from relatives or friends are not accepted.

Name:

Status:

Address and Telephone No:

Name:

Status:

Address and Telephone No:

Name:

Status:

Address and Telephone No:

This organisation seeks to work in a flexible and family friendly manner with its staff, however unsocial hours are part and parcel of a quality care service. Weekend working is a requirement for all staff, the frequency of which will be determined at interview.

Please indicate holiday dates if already booked

Period of notice required in present post

Earliest start date

Thank you for completing this application form.

I declare that to the best of my knowledge, all the information contained and documented herein is complete and truthful.

Confirm the above information is correct. *Check

Date *

EQUAL OPPORTUNITIES MONITORING

EQUAL OPPORTUNITIES MONITORING

This section of the application will be detached and used for monitoring purposes only. Our organisation recognises and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect in line with the Equality Act 2010 legislation. We welcome applications from all sections of the community.

Date of Birth:

GenderMaleFemaleI do not wish to disclose this

Race Relations (Amendment) 2000

I would describe my ethnic origin as (please check any option below):

Please select the option which best describes your sexuality.

Please indicate your religion or belief

HEALTH QUESTIONNAIRE

HEALTH QUESTIONNAIRE

(To be used for those applicants that have been deemed appointable).

To comply with the Equality Act 2010, please complete this questionnaire as fully as possible. Failure to do so could impede or delay your appointment. All information is confidential.

Have you ever had or suffered from?

Are you registered disabled?YesNo

If you're registered disabled, please leave details below:

Please List Below any Periods spent Outside of the United Kingdom as a Resident (do not include holidays)

Please List below any vaccinations or immunisations

Date

Immunisation

Expiry

Date

Immunisation

Expiry

Date

Immunisation

Expiry

Date

Immunisation

Expiry

I declare that the information given is correct to the best of my knowledge. In my view, I am fit physically and mentally to undertake this post. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references.

Confirm the above information is correct. *Check

Date *

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