APPLICATION FORM

REVIEWED APRIL 2011

Successful applicants will be subject to Enhanced Disclosure from the Criminal Records Bureau.
As an equal opportunities employer we aim to recruit on the basis of general suitability for the position applied for and also consider age, sex,
marital status, disability and ethnic origin.

POSITION APPLIED FOR:

PERSONAL DETAILS

Name Mr/Mrs/Miss/Ms

Address Telephone
Mobile No
Date of Birth
Nationality
E-mail
Post Code National Insurance number
Next of Kin/Emergency Contact

Name Mr/Mrs/Miss/Ms

Relationship to applicant

Address Telephone
Mobile No
Email:
Post Code

Date available to start work:

Hours required per week: Availability:

If employed would you be available at short notice?

Where did you hear about this job position?

EMPLOYMENT HISTORY

Name and Address of current or most recent employer From: To:

Job description and main duties performed

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 EMPLOYMENT HISTORY CONT…

Previous Employment – please list in date order all previous employment please account for all gaps in employment.
Name and address of Post held and main duties performed Worked Worked Reason for leaving
employer from to

EDUCATION & QUALIFICATIONS

Name of school/college Subject studied Qualification/Level Date gained

university/training body

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EMPLOYMENT DECLARATION
Have you ever worked for another social care organisation either within this county or throughout the UK? If so
please give details below:

REFERENCES

Please provide the name and details of two people who can provide a reference for you. One of these references
should include your current or most recent employer.
Referee 1

Name Mr/Mrs/Miss/Ms

Address Telephone
Mobile No
Email
Post Code

How is this person known to you?

Referee 2

Name Mr/Mrs/Miss/Ms

Address Telephone
Mobile No
Email
Post Code

How is this person known to you?

Availability Declaration

I understand that the work with Blue Ribbon involves what is considered unsociable hours. The requirements of the
job mean I will be working a number of evenings, weekends and Bank Holidays:

Signed:

Date:

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TRAVEL

Do you have a driving licence Yes No

Availability of car for work Yes No

Do you have any endorsements Yes No

If Yes please give details

CRIMINAL RECORDS

Due to the sensitive nature of the work which you are applying for, this application is exempt from the
Rehabilitation of Offenders Act 1974. This means that all convictions, cautions, reprimands and final
warnings on your criminal record need to be disclosed. If you are recruited and have failed to disclose
a criminal record you will be subject to Blue Ribbon’s disciplinary procedures.

Have you ever:

 Been convicted by the courts or cautioned, reprimanded or been given a final warning by the
police? YES/NO

 Any awareness of police enquiries undertaken following allegations made against you? YES/NO

Please list below any Criminal Record Declarations

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 ABILITY CHECK LIST:
Please tick to indicate your experience – it could be work related or personal experience
Personal hygiene Practical tasks
Bath/shower/strip wash Light housework
Bed bath Washing personal laundry
Use of bath aids Shopping
Shaving Bed making/changing a bed
Mouth care
Care of hair
Care of feet Administration
Care of fingernails Report writing
Dressing / undressing Recording instructions from GP/nurse
Care of eyes Recording changes in client’s condition

Toileting Previous experience

Continence care Private Client Care
Bedpans/commodes etc. Nursing or Residential Home
Emptying a catheter bag Hospital
Stoma care Domiciliary Care

Mobility Client group experience

Lifting and handling Older people
Use of hoist Terminal illness
Use of walking aids Physically disabled
Moving and handling of clients HIV / AIDS
Mental health
Observation Learning disabilities
Temperature Child care
Pulse Other
Respiration
Urine testing Nutrition
Blood pressure Preparing meals
Feeding
Food handling
Any further information you may wish to provider:

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WORKING TIMES REGULATIONS DECLARATION

If you do wish to work more than 48 hours per week, it is necessary to sign the form below to
show that you are available.

I (name) ____________________________________ confirm that I want to be able to work

more than 48 hours per week and that I will give you adequate notification in writing should I wish
to reduce these hours to less than 48 hours..

Signed ______________________________________

Dated ______________________________________

I am eligible for employment in the UK and I am physically and mentally fit for work. To my knowledge all the
information I have provided on this application form is a true and complete record. I also acknowledge that the
contract of employment Act 1972 applies to this application.

Signature of Applicant

Date of Signature

All information provided is subject to our confidentiality policy and the Data protection Act

Please ensure that you return completed application forms to your local office.

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