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Please complete all the fields in this form.

PERSONAL DETAILS

Name

First Last

Mobile telephone number*

Email

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Are you registered with Social Care Wales?

Yes

No

If answered yes, what is your registration number?

Next of Kin Details

NEXT OF KIN DETAILS

Name

Address

Relation

Contact Number

Bank Details

Who you bank with

Sort Code

Account Number

National insurance number.*

Employee Statement

A – This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance, Employment and Support Allowance, taxable Incapacity Benefit, State or Occupational pension.

B – This is now my only job, but since last 6 April I have had another job, or received taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit. I do not receive a State or Occupational Pension.

C – As well as my new job, I have another job or receive a State or Occupational Pension.

HEALTH

Do you have any health complaints which may be relevant to this job application?

Yes

No

If ‘YES’ please describe them

Overall state of health

Excellent

Good

Poor

Hearing

Excellent

Good

Poor

Eyesight

Excellent

Good

Poor

DRIVING RECORD

Do you hold a valid UK Driving Licence?

Yes

No

Do you have your own Car?

Yes

No

Number of penalty points (if any) endorsed on current licence?

Have you ever been disqualified from driving or had insurance refused?

Yes

No

If ‘Yes’, please provide brief details

Do you have a passport, work permit or other documents to show that you are entitled to work in the UK, as you will to provide copies prior to starting your employment?

Yes

No

CAUTIONS/CONVICTIONS

The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013 and 2020) provides that when applying for certain jobs and activities, certain convictions and cautions are considered 'protected'. This means that they do not need to be disclosed to employers, and if they are disclosed, employers cannot take them into account.

Do you have any convictions or cautions (excluding youth cautions, reprimands or warnings) that are not "protected" as defined by the Ministry of Justice?

Yes

No

If ‘Yes’, please provide brief details

TRAINING AND SKILLS

Date

Duration

Course/Training completed

EXPERIENCE

Please outline your experience including details of your present or previous duties in your job which you consider are relevant to this application.

REFERENCES

Please Provide at least TWO References

Reference #1*

Name of reference #1 (Required)

Email of reference #1 (Required)

Phone Number of reference #1

Current or Previous employer/character reference

Reference #2*

Name of reference #2 (Required)

Email of reference #2 (Required)

Phone Number of reference #2

Current or Previous employer/character reference

Reference #3

Name of reference #3

Email of reference #3

Phone Number of reference #3

Current or Previous employer/character reference

Reference #4

Name of reference #4

Email of reference #4

Phone Number of reference #4

Current or Previous employer/character reference

Name*

First Last

Date*

Signature for Consent*

I Consent For Cadog Homecare LTD to contact my references*

I agree to the above.

PERSONAL SKILLS & ATTRIBUTES

Please describe your skills and attributes which will support your application.

JOB FLEXIBILITY

When completing the below, please be aware that there is a need for weekend working from every member of staff. To ensure fairness we impose an alternating weekend pattern. This allows opportunities and fairness for all with days off.

Available To Take up Employment

Please provide details of your working notice/start date for employment with Cadog homecare Ltd.

Notes

Working Time Regulations

You cannot work more than 48 hours a week on average - normally averaged over 17 weeks. This law is sometimes called the ‘working time directive’ or ‘working time regulations’. You can choose to work more by opting out of the 48-hour week. You can choose to work more than 48 hours a week on average if you’re over 18. This is called ‘opting out’. Your employer can ask you to opt out, but you cannot be sacked or treated unfairly for refusing to do so. You can opt out for a certain period or indefinitely.

Consent and Agreement Form

I, , agree that I may work for more than an average of 48 hours a week. If I change my mind, I will give my employer one month's notice in writing to end this agreement.

I agree to this statement I disagree to this statement

Rehabilitation of Offenders Act 1974 Through the 1975 exemptions Order of the Rehabilitation of Offenders at, 1974 and by virtue of the nature of the post for which you are applying, we are obliged, as your prospective employers, to ask the following questions. Any information supplied by yourself will remain confidential and considered only in relation to the Job Application: With the exception of minor motoring offence(s), have you ever been convicted of any criminal offence by a Court of Law?

Please Select

Yes

No

If ‘YES’, please provide brief details of the offence(s) and relevant dates:

By signing the agreement you confirm the information in this form is accurate at the time of completing.

Name

First Last

Date

Signature

Wet Signature (FOR HR ONLY)

FOR HR ONLY

Declaration

I certify that the information given in this application is to the best of my knowledge and belief complete and correct. I agree to comply with the requirements specified. I am aware that if it is discovered that I have withheld, omitted or misrepresented any facts in this application, any Application granted would be liable to cancellation and I may be liable to prosecution. I agree to comply with the Regulations which apply and the relevant National Minimum Standards.

Consent for release of personal data for employment purposes.

This form I to be complete by the person applying for employment with Cadog homecare Ltd so references and past employment information can be obtained. Please be aware that the information provided will only be viewed by Cadog homecare Ltd and will not be shared with any third parties.

Signature

Please sign.

Date

By completing this form I consent to the transfer of my information to the disclosure and barring service for the purpose of a Disclosure Application and I have read and agree to the ‘statement of Fair processing.

Application Declaration

Declaration

Please tick to confirm that you have agreed to the Applicants Declaration.

Privacy Policy - Standard/enhanced checks. (Paper & e-bulk applications)

I have read the standard/Enhanced Check Privacy Policy applicants (DBS privacy policy) and I understand how DBS will process my personal data and options available to me for submitting the application. https://www.gov.uk/government/publications/dbs-privacy-policies

Confirmation of Privacy Policy

Please tick to confirm that you have agreed to the Privacy Policy.

Consent to obtain e-Bulk standard/enhanced check electronic result

I consent to the DBS providing an electronic result directly to the registered body that has submitted my application. I understand that an electronic result contains a message that indicates either the certificate is blank or to await certificate which will indicate that my certificate contains information. In some cases the registered body may provide this information directly to my employer prior to me receiving my certificate.

Do you Consent?

Yes, I consent.

No, I do not consent

Signature

Please sign.

Date

DBS information checks
All information you supply will be photocopied and kept on file for the duration of your employment with Cadog homecare Ltd.

Name

First Last

Other Names (You have been known by)

Surname:

Used from: (dd/mm/yy)

Used to: (dd/mm/yy)

Date of Birth

Town and county you were born:

Current address please inc your postal code*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date you moved to this address

Email Address*

Past Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

If you haven’t lived at your address for MORE than five years, please add addresses to cover the past five years.

Passport Number

Country of issue

Nationality

Date of Issue

Expiry Date

Driving Licence Number

Date of Issue

Expiry Date

Country of issue

Please attach at least two letter that prove you live at your current address, these can be bank statements/utility bills/benefits letters/council tax letters.

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 5 MB, Max. files: 6.

(They must be within the last three months).

PERSONAL DETAILS

Next of Kin Details

Bank Details

Employee Statement

HEALTH

DRIVING RECORD

CAUTIONS/CONVICTIONS

TRAINING AND SKILLS

EXPERIENCE

REFERENCES

PERSONAL SKILLS & ATTRIBUTES

JOB FLEXIBILITY

Available To Take up Employment

Working Time Regulations

What is your ethnicity?

Health

Application Declaration

Privacy Policy - Standard/enhanced checks. (Paper & e-bulk applications)

Consent to obtain e-Bulk standard/enhanced check electronic result