Employment Application

Application to the Post of*

How did you hear of this post?

PERSONAL

Surname*

First Name(s)*

Title*
MrMrsMissMs

Date of Birth*

Address*

Contact Number*

Contact Email*

Nationality*

Do you require a permit to work in the UK?*
NoYes*

*If Yes – Provide (upload) a copy of evidence for your Permit to Work in the UK

Do you hold a Full Driving Licence?*
NoYes

EMPLOYMENT

Are you currently employed?*

*Provide (upload) Work related document

If currently Employed, provide details including: Company Name / Name of Present Employer, Address, Telephone Number, Nature of Business, Job title and brief description of duties.

National Insurance Number*

List details of previous Employment - latest first. Excluding present employment. Include Name and Address of Employer, Position Held/ Main Duties and Dates.

QUALIFACATIONS

Attach CV

List any Formal Training and/or Job related Training Courses. Include Qualifications with dates and Name of Awarding Bodies.

Are you registered with the NMC?*
NoYes*

*If registered, provide Membership PIN Number:

*If registered, provide Renewal Date

REFEREES

Provide details of two persons to whom reference can be made. The first should be your present or last employer. Include Name, Position, Address and Telephone No.

Reference 1

Reference 2

Can we approach your current employer before an offer of employment is made?*
NoYes

Are you required to give notice to your present employer?*
NoYes*

*If Yes – How much notice?

PERSONAL HEALTH BACKGROUND

Select if you are suffering or have suffered any of the following:
DiabetesHigh Blood PressureEpilepsyBack Pain or InjuryRecurrent HeadachesT.B.MigraineMental Illness, DepressionAny Heart ConditionSkin Conditions

List any medication you are currently taking:

List any surgery you have had (including dates):

Are you allergic to anything?

List all absences from work in the past 12 months – stating reason of absence:

Are you registered disabled?*
NoYes*

*If Yes – Provide Registration Number:

Medical Declaration

I herby confirm that to the best of my knowledge I have not been aware of, or have never been advised of any reason by way of mental or physical incapacity that may deem I am not fit to carry out the duties for the position to which this application relates.

I Accept

Date:

DECLARATION

Have you been employed by us previously?*
NoYes*

*If Yes – provide dates:

Are you involved in any activity that may limit your availability to work?*
NoYes

*If Yes – provide full details:

You understand and accept you may be required to work overtime from time to time*
NoYes*

Do you have any criminal convictions, cautions, reprimands, final warnings, police enquiries or pending prosecutions against you, including any convictions which are regarded as ‘spent’ under the Rehabilitation of Offenders Act 1974?*
NoYes*

*If Yes, provide full details. (Any such information will be treated confidentially)

I declare that the information provided above is complete and accurate. I understand that any false information or deliberate omissions gives my employer the right to terminate any employment contract at any time. I understand these details will be held in confidence by the company, for the purposes of assessing this application, on-going personnel and payroll administration (where applicable) in compliance with the Data Protection Act 1998. I understand Lancashire Care Services Ltd reserves the right to require me to undergo a medical examination at any time during my employment by a party nominated by Lancashire Care Services Ltd.

I Accept

Signed* (type signature)

Date:

PREFERENCE OF DUTIES

Day Shift’sNight Shift’sWeekdaysWeekendsAny Shift

NOTE: All required fields need to be completed and consents accepted in order to submit.