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EDEN COUNTRY CARE LTD

APPLICATION FORM

PERSONAL DETAILS

NAME:

ADDRESS:

POSTCODE:

TEL/HOME: TEL/MOBILE:

EDUCATION

NAME ADDRESS OF SCHOOL/ QUALIFICATION

COLLEGE/UNIVERSITY GAINED

REVIEW DATE JAN2112

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OTHER QUALIFICATIONS

DETAILS

HOBBIES/INTERESTS

DO YOU HAVE A DRIVING LICENCE? YES/NO

DO YOU HAVE YOUR OWN TRANSPORT? YES/NO

REVIEW DATE JAN2112

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GENERAL EXPERIENCE

WHICH ASPECTS OF YOUR WORKING OR LIFE EXPERIENCE DO YOU THINK ARE

PARTICULARLY RELEVANT TO THE POSITION APPLIED FOR?

MEDICAL HISTORY

PLEASE STATE WITH DATES ANY SERIOUS ILLNESSES, OPERATIONS, OR

HEALTH PROBLEMS THAT YOU MAY HAVE OR HAVE HAD IN THE PAST.
(If none state none)

DATES DETAILS

ARE YOU PHYSICALLY FIT?.......................(Y/N)

HAVE YOU EVER SUFFERED FROM BACK, NECK OR SHOULDER
INJURIES?................(Y/N)

DATES DETAILS

PLEASE GIVE DETAILS OF ANY SICKNESS ABSENCES IN LAST 12 MONTHS

DATES DETAILS

REVIEW DATE JAN2112

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PREVIOUS EMPLOYMENT (Including periods of unemployment)

(NO CVs PLEASE)

Name and full postal address ( including postcode Date Date Position held/Duties
and telephone number) from to carried out

TEL: POSTCODE

TEL: POSTCODE

TEL: POSTCODE

TEL: POSTCODE

TEL: POSTCODE

TEL: POSTCODE

REVIEW DATE JAN2112

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CRIMINAL RECORD CERTIFICATES (See next sheet for more information)

Because of the sensitive nature of the duties that the post-holder will be expected to undertake, you are required
to disclose details of any criminal record. Only relevant convictions or other information will be taken into
account, so disclosure need not necessarily be a bar to obtaining this position.

1) Have you ever been convicted by the courts or cautioned or reprimanded or given a final warning by
the police? ( Note the post you have applied for is excepted under the Rehabilitation of Offenders Act 1974,
which means that all convictions, cautions reprimands and final warnings on your criminal record need be
disclosed.)
YES/NO.................
If yes please give details below of offences and penalties and dates.

2) Are you aware of any police enquiries undertaken following allegations made against you, which may
have a bearing on your suitability for this post?
YES/NO.................
If yes please give details below.

REVIEW DATE JAN2112

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CRIMINAL RECORD CERTIFICATES

If the position you are applying for (whether paid or voluntary) is listed in Schedule 1, Part 2
of the Rehabilitation of Offenders Act (Exceptions) Order 1975, Eden Country Care Limited
is entitled to ask Exempted Questions as defined by Section 113(5) of the Police Act 1997
about you. From July 2002 Eden Country Care Limited is required by The Domiciliary Care
Agencies Regulations 2001 to obtain a criminal record certificate in relation to any person
who is a care manager or domiciliary care worker.

This means that if your application is successful we will obtain from the Criminal Records
Bureau a criminal record certificate relating to you, before your appointment is confirmed.
You are, however, encouraged to tell us about your criminal record before we obtain a
criminal certificate.

Having a criminal record will not necessarily bar you from working with us .
This will depend on the nature of the position and the circumstances and background of your
offences. Eden Country Care Limited has a written policy on the recruitment of ex-offenders
and we will give you a copy of it on request. Eden Country Care Limited observes the “Code
of Practice for registered persons and Other Recipients of Disclosure Information” published
by the Criminal Records Bureau at www.crb.gov.uk on behalf of the Home Office, and we
will give you a copy of it on request.

DECLARATION

I understand if I am employed by Eden Country Care that any misleading or false statements
on this form may be considered cause for termination of my employment.
I understand that my signature on this form give the company permission to make enquiries
about me with any previous employers. (Your present employer will not be approached until
an offer has been accepted)

I declare that I believe that the information I have given on this application form is true.

SIGNED...........................................................................DATE.........................................

REVIEW DATE JAN2112