C & S Care Services

Application Form

Please complete the following form. Fields marked * are required.

Surname *

Forename(s) *

Date of birth *

Nationality *

Ethnic Origin *

Marital Status *

Gender *

Address *

Post Code *

Home Telephone *

Mobile

Position Applying For *

NI Number *

School Qualifications *


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Please list names of employers since leaving school, period of working with each employer and reason for leaving starting with your current employment


Current Employer *

Period of Employment *		(ie. 2004-Present)

Reason for Leaving *


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Previous Employer

Period of Employment

Reason for Leaving


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Previous Employer

Period of Employment

Reason for Leaving


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Current Wage *

Do you hold a Current Full Driving Licence? *	Yes No

Experience and Skills *		Please give details of any experience and skills you have relating to the job of a care worker


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Please give names, addresses & telephone numbers of two referees from your present place of work, one must be your present manager. (MUST be EMPLOYMENT references).


Ref1 Name *

Ref1 Address *

Ref1 Telephone *


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Ref2 Name *

Ref2 Address

Ref2 Telephone *


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Do you have Health Problems? *	Yes No

If 'Yes' please give brief details


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CRIMINAL RECORD CERTIFICATES: If the position you are applying for (whether paid or voluntary) is listed is schedule 1, Part 2 of the Rehabilitation of Offenders Act Order 1975, C & S Care Services is entitled to ask Exempted Questions as defined by Section 113(5) Of the Police Act 1997 about you. From July 2002 C & S Care Services is requires by The Domiciliary Care Agencies Regulations 2001 to obtain a criminal record certificate in relation to any person who is 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 record certificate.


Do you have a prosecution pending or have you ever been convicted by a court or cautioned by the police for any offence? *	Yes No


If yes , please provide details below of pending prosecutions, convictions, cautions and bind over orders, including approximate date, the offence and the court or police force which dealt with the offence


Details


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. C & S Care Services Ltd. has a written policy on the recruitment of ex offenders and we will give you a copy of it on request. C & S Care Services Ltd. 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.



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


I CONFIRM THE ABOVE DECLARATION TO BE TRUE *	I CONFIRM

Date *		Click the button to browse for the date using the calendar