Personal Details
Date of Birth
*
Address Line 1
*
Address Line 2
Town
*
Postcode
*
Mobile Number
*
Home Phone Number
Do you have care experience
*
EDUCATION
Do you hold a qualification NVQ level or above? If so please add the courses below and qualifications gained
*
Please confirm the dates you started and left full time education
*
EMPLOYMENT HISTORY
Please note we require a FULL employment history from your first day of work to your last If there is no space on the application please attach your CV at the bottom of the application or a sheet with your full employment history Please ensure employment dates are correct as these will be crossed checked with dates provided from references
If there are any gaps in your employment please confirm dates and reasons for all gaps (This is for all gaps that were over 2 weeks)
CURRENT/MOST RECENT EMPLOYMENT
Position held
*
Name of Employer
*
Address of employer
*
Notice Period
*
Describe your duties / responsibilities
*
Reason for leaving / seeking change
*
Date started
*
Date ended (if applicable)
Past Employment Position 1
Position
*
Name of Employer
*
Employer Address
Date Started
Date Ended
Reason for leaving / seeking change
*
Past Employment Position 2
Position
Name of Employer
Employer Address
Date Started
Date Ended
Reason for leaving / seeking change
*
Past Employment Position 3
Position
*
Name of Employer
*
Employer Address
Date Started
Date Ended
Reason for leaving / seeking change
*
Past Employment Position 4
Position
*
Name of Employer
*
Employer Address
Date Started
Date Ended
Reason for leaving / seeking change
*
Past Employment Position 5
Position
*
Name of Employer
*
Employer Address
Date Started
Date Ended
Reason for leaving / seeking change
*
PLEASE ENSURE YOU HAVE INCLUDED YOUR FULL EMPLOYMENT HISTORY FROM FIRST DAY OF WORK TO LAST You can upload a CV or continuation sheet to the bottom of this form
If you had ANY gaps in employment please include ALL dates here and reason for gaps This is for all gaps that were over 2 weeks
*
References
FOR THOSE THAT HAVE NOT WORKED IN CARE BEFORE (THIS INCLUDES WORKING WITH ADULTS OR CHILDREN) We require references covering a minimum of 5 years employment history starting from your current/most recent employer. If you don't have a minimum of 5 years employment history please provide as many employment references as you can and then education/volunteer/character References (must not be relatives)
FOR THOSE THAT HAVE WORKED IN CARE (THIS INCLUDES WORKING WITH ADULTS OR CHILDREN) If you have worked in care please provide a reference for EVERY care position you have had (regardless of how long ago this was) We require references covering a minimum of 5 years employment history starting from your current/most recent employer
PLEASE NOTE Employment references provided must be for a Manager or HR Department If you provide reference details for a colleague this can only be used as a character reference
Referee 1
Reference 1 Full Name
*
Capacity of reference (Employer, personal or education)
*
Please note a work colleague would be classed as a personal reference unless they were your manager/senior
If reference is a past employer please add the company name
*
Contact Email address
*
Contact number
*
Referee 2
Reference 2 Full Name
*
Capacity of reference (Employer, personal or education)
*
Please note a work colleague would be classed as a personal reference unless they were your manager/senior
If reference is a past employer please add the company name
*
Contact Email address
*
Contact number
*
Referee 3
Reference 3 Full Name
Capacity of reference (Employer, personal or education)
*
Please note a work colleague would be classed as a personal reference unless they were your manager/senior
If reference is a past employer please add the company name
Contact Email address
Contact number
Referee 4
Reference 3 Full Name
Capacity of reference (Employer, personal or education)
*
Please note a work colleague would be classed as a personal reference unless they were your manager/senior
If reference is a past employer please add the company name
Contact Email address
Contact number
Right to Work
By law all employers in the UK have a responsibility to prevent illegal working by conducting simple right to work checks before employment commences The right to work check will be carried out at your shadow shift. You will be emailed a list of acceptable documents to bring with you to carry out your right to work check. Please note: If you have a biometric card. Holders can no longer use their physical card as evidence of a right to work, and are now required to use the Home Office online service to provide a share code
In accordance with the Asylum and Immigration Act 1996, do you require a work permit to undertake work in the UK?
*
What is your nationality? If you have multiple nationalities, please list them.
*
If you have a current permit, please state permit type, permit number, expiry date
If you have a share code please provide this here
Rehabilitation of Offenders Act 1974 (exceptions) Order 1975
The post you have applied for is exempt from the Rehabilitation of Offenders Act 1974 because of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 which exists to protect certain vulnerable groups within our society. You are not entitled to withhold any information about convictions or other relevant criminal record information which for other purposes are spent under the provisions of the Act. If you are successful with this application, any failure to disclose such information could result in dismissal or disciplinary action. Any information provided will be confidential.
You are applying for a position which involves regulated activity and are required to have an enhanced criminal records check and, where appropriate to the role, this check will also include any information which may be held against the barred lists for working with children and/or adults.
Are you currently bound over or have you ever been convicted of any offence by a court or court-martial in the United Kingdom or in any other country?
*
If YES, please include details of the order binding you over and/or the nature of the offence, the penalty, sentence or order of the court, and the date and place of the court hearing. You do not need to tell us about parking offences.
Are you currently bound by any barring decision made by the Independent Safeguarding Authority (ISA) from working with children?
*
Are you currently bound by any barring decision made by the Independent Safeguarding Authority (ISA) from working with vulnerable adults?
*
Data Protection
Relevant details from this form will be retained as part of your employment records if you are appointed. This information will be used for personal administration and the work of BelleVie in accordance with the Data Protection Act 1998.
Authorisation and Declaration
I authorise BelleVie to obtain references to support this application.
I consent to the details being retained confidentially and used for specific lawful purposes in connection with the Data Protection Act 1998.
I confirm that the above information is correct and complete, and understand that failure to disclose information OR any misrepresentation or false information contained in this application and its enclosures may be sufficient grounds for terminating employment.
Equal Opportunities
BelleVie is committed to Equal Opportunities and as such wishes to ensure that all applicants are treated fairly and without discrimination whatever their race, colour, ethnic background, marital status, gender, sexuality, age, or disability.
To help us monitor this, we would appreciate if you would complete this questionnaire. The information will be used solely for monitoring purposes and will be treated with confidentially.
Do you consider yourself disabled?
The Disability Discrimination Act 1995 defines a disabled person as someone who has: ‘A physical or mental impairment which has substantial and adverse long term effects on his/her ability to carry out normal day to day activities.’
If you consider yourself disabled, please complete this section in order that suitable arrangements can be made if called for an interview. Please return this with your application form. This information will not be used in deciding suitability for a post.
Do you have a health problem or disability, which you feel is relevant to this job application e.g. difficulty moving up and down stairs, or a hearing or speech problem? If so, please give details below.
