Position Applied For:

Title MrMrsMissMsOther

Surname:

Forename(s):

Address:

Postcode:

Telephone Numbers
Private:
Business:
Mobile:

Email:
This email address is:

Date of Birth:

National Insurance Number

Do you need a permit to work in the UK? YesNo

Next of Kin:
Relationship to you:
Contact Number:

Driving Record:
Do you have regular use of a car? YesNo

Make / model / year:

Current Driving Licence: ProvisionalFullPSVNone
Driving Licence valid from:
Driving Licence valid to:
Details of current endorsements (if any):

Do you have any driving-related prosecutions / fixed penalties / endorsements or similar currently pending? YesNo
If “YES” please provide brief details:

Have you ever been disqualified from driving? YesNo
If "YES" please provide brief details:

Have you ever had insurance refused? YesNo
If "YES" please provide brief details:

EDUCATION & PROFESSIONAL TRAINING (from year 11)

Secondary Education (secondary school):
Date from:
Date to:
Qualifications gained:

Higher Education (university / college / polytechnic):
Date from:
Date to:
Qualifications gained:

Further Education (Professional Training):
Date from:
Date to:
Qualifications gained:

Membership of Professional Organisations:

LANGUAGES (other than English) if any:

Language 1:
Fluency in this Language: SpokenFluentWrittenRead

Language 2:
Fluency in this Language: SpokenFluentWrittenRead

Language 3:
Fluency in this Language: SpokenFluentWrittenRead

Personal DBS Certificates

If the position you are applying for (whether paid or voluntary) is listed in Schedule 1, Part II of the Rehabilitation of Offenders Act (Exceptions) Order 1975, we are entitled to ask Exempted Questions as defined by Section 113(5) of the Police Act 1997 about you. We are required to check a DBS Certificate in relation to any person who is a Care Manager or Care Worker. If your application is successful and before your appointment is confirmed, you will be required to submit a personal current and valid DBS Certificate for our inspection.

Having a criminal record will not necessarily bar you from working with us. This will depend upon the nature of the position and the circumstances and background of your offences. We observe the “Code of Practice for Registered Persons and Other Recipients of Disclosure Information” published through the Disclosure & Barring Service on behalf of the Home Office, and we will provide you with a copy of it upon request.

EMPLOYMENT HISTORY

Employer:
Date from:
Date to:
Salary:
Positions held:
Reasons for leaving:

Employer:
Date from:
Date to:
Salary:
Positions held:
Reasons for leaving:

Employer:
Date from:
Date to:
Salary:
Positions held:
Reasons for leaving:

Employer:
Date from:
Date to:
Salary:
Positions held:
Reasons for leaving:

Employer:
Date from:
Date to:
Salary:
Positions held:
Reasons for leaving:

JOB FLEXIBILITY

Prepared to work (may select more than one): Full timePart timeShifts

If PART TIME please indicate preferred hours:

Details of any other work which you will continue to undertake if you are offered this Job Position (if none, please enter NONE):

Please provide details of any outstanding holidays to be taken (if none, please enter NONE):

AVAILABLE TO TAKE UP EMPLOYMENT FROM:

REFERENCES

Please provide details of 2 employment references or 3 character references who we may approach with regards to
this Job Application. These referees must not be members of your family, and one must be your present or most
recent employer:

Name:
Occupation/ Job Position:
Email Address:
Contact Number:
In what capacity do they know you and for how long?

Name:
Occupation/ Job Position:
Email Address:
Contact Number:
In what capacity do they know you and for how long?

Name:
Occupation/ Job Position:
Email Address:
Contact Number:
In what capacity do they know you and for how long?

May we contact your referees prior to making a job offer? YesNo

DECLARATION BY JOB APPLICANT

ANY PERSON, UPON SUBSEQUENT EMPLOYMENT, THAT IS FOUND TO HAVE KNOWINGLY SUPPLIED FALSE OR MISLEADING INFORMATION, OR HAS DELIBERATELY WITHHELD RELEVANT INFORMATION, MAY BE SUBJECT TO DISCIPLINARY PROCEEDINGS WHICH MAY RESULT IN DISMISSAL.

I have read and understood the information supplied to me in relation to this Job Position, and the information requested in this Job Application Form. I confirm that all information supplied by me is true and correct to the best of my beliefs. I give the prospective employer the right to follow up all references and to make any other job-related enquiries as may be deemed necessary.

BLUEBOARD CARE SERVICES LTD IS AN EQUAL OPPORTUNITIES EMPLOYER

The sole criterion for selection of applicants will be suitability for the Job Position, regardless of gender, background, culture, ethnic denomination, religious affiliation, marital status or disability. Data Protection Act 1998: Your signature on this document gives us the right, under the Data Protection Act 1998 to process the
information you have given, including data of a sensitive nature, relating to your application for employment. Any processing of the data by us will be in accordance with our Policy and the processing principles set out in the Act. Application forms of unsuccessful candidates will be destroyed after 6 months in accordance with our Record-keeping Policy.

Form No: 03-1-200