Application for Employment

Position applied for*
Name*
Title Forename(s) Family Name
Address*
Address City Postcode
Home Phone Number*
Mobile Number*
Marital Status*
Previous Name (if applicable)
Are you aged 18 years of above?*
- Yes
- No
Do you hold a current, full Driving Licence?*
- Yes
- No
Would you be using your car for work?*
- Yes
- No
National Insurance Number*
Are you registered to work within the United Kingdom?*
- Yes
- No
Email Address*
Enter Email Confirm Email
Employment History
You must provide a COMPLETE employment history since leaving full time education, providing explanations for any lack of continuity or breaks in employment. Please also provide details of any unpaid/voluntary work. Applications cannot be processed until this is completed.
Start Date*

Day
Month
Year
End Date*

Day
Month
Year
Employer Name and Address*
Position and Duties*
Reason for leaving*
Start Date*

Day
Month
Year
End Date*

Day
Month
Year
Employer Name and Address*
Position and Duties*
Reason for leaving*
Please use the space to tell us about additional employment history if applicable
Qualifications & Education
Please give details of all qualifications and where you gained them. AS A MINIMUM, YOU MUST INCLUDE THE SCHOOL YOU ATTENDED AND DATES.
Name of Establishment (School, College, University, etc.)*
Qualifications (e.g. GCSE, A Level, NVQ, etc.)*
Start Date*

Day
Month
Year
End Date*

Day
Month
Year
Name of Establishment (School, College, University, etc.)*
Qualifications (e.g. GCSE, A Level, NVQ, etc.)*
Start Date*

Day
Month
Year
End Date*

Day
Month
Year
Name of Establishment (School, College, University, etc.)*
Qualifications (e.g. GCSE, A Level, NVQ, etc.)*
Start Date*

Day
Month
Year
End Date*

Day
Month
Year
Qualifications in Health & Social Care
References
Please give details of two people that we can contact to obtain work references. Please note that references cannot be obtained from members of your extended family and they must have known you for a minimum of two years and hold a . One reference must be for your current/immediately previous employer. If you have previously been employed in the care sector, worked with children or vulnerable adults, then we are also obligated to contact all such employers for additional statements. If you have only had one job since leaving Education, we can take a Character reference as the second reference however this would need to be 'a person of good standing in their community' or work in (or be retired from) a recognised profession and known you for a minimum of 2 years.
Employer Name (Reference 1)*
Title Family Name Forename(s)
Company Name (Reference 1)*
Address (Reference 1)*
Address City Postcode
Phone Number (Reference 1)*
Email Address (Reference 1)*
Employer Name (Reference 2)*
Title Family Name Forename(s)
Company Name (Reference 2)*
Address (Reference 2)*
Address City Postcode
Phone Number (Reference 2)*
Email Address (Reference 2)*
Any other positions in care please provide references here
Statement of Fitness
Due to the physical nature of the work and the safe manual handling techniques required for reasons of Health and safety, it is an intrinsic function of the job role that staff have generally good physical fitness and be able to kneel down from a standing position and stand back up without assistance. Mobile Care Services Ltd is committed to equal opportunities and will always strive to make reasonable adjustments to working environments so far as is practicable, providing we are made aware of such issues. Please sign the statement below to confirm that you consider yourself physically, mentally and emotionally fit for the position applied for. Should you have any queries regarding the physical requirements of the position, please do not hesitate to contact me for an informal discussion.
Statement of Fitness (Confirmation)*
- I confirm that at the time of completing this application, I consider myself to be physically and mentally fit for the position applied for, as detailed in the job description provided by Mobile Care Services Ltd.
Criminal Convictions
Due to the nature of the role for which you are applying, this post is exempt from the provisions of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. All applicants are therefore required to disclose any spent or unspent convictions, cautions, reprimands, penalty notices and final warnings that they have received. In accordance with the Care Standards Act 2000, we are also required to obtain an Enhanced DBS Check which checks your details against the Police National Computer, local Police Records, matters currently under investigation and any lists held by the Department of Health and the Department of Education, which detail individuals considered unsuitable to work with children or vulnerable adults. Failure to disclose details of anything listed below could result in dismissal if the Disclosure obtained in your name does not correspond with the details you provide. ***You must answer truthfully to the questions below, as they will appear on your Enhanced Disclosure, regardless of the length of time passed.***
Have you any previous spent or unspent Criminal Convictions given by the Courts/Police?*
- Yes
- No
Please provide full details*
When did it occur? Please describe in detail the circumstances of the situation. Were there any other individuals involved? Could this situation occur again? If not, why not? On reflection what do you think about the above matter?
Have you ever been cautioned or received a reprimand by the Courts/Police?*
- Yes
- No
Please provide full details*
When did it occur? Please describe in detail the circumstances of the situation. Were there any other individuals involved? Could this situation occur again? If not, why not? On reflection what do you think about the above matter?
Have you ever received a final warning by the Courts/Police?*
- Yes
- No
Please provide full details*
When did it occur? Please describe in detail the circumstances of the situation. Were there any other individuals involved? Could this situation occur again? If not, why not? On reflection what do you think about the above matter?
Have you ever been questioned by the Police regarding a Criminal Offence?*
- Yes
- No
Please provide full details*
When did it occur? Please describe in detail the circumstances of the situation. Were there any other individuals involved? Could this situation occur again? If not, why not? On reflection what do you think about the above matter?
Are you currently under investigation or do you have any prosecutions pending by the Courts/Police?*
- Yes
- No
Please provide full details*
When did it occur? Please describe in detail the circumstances of the situation. Were there any other individuals involved? Could this situation occur again? If not, why not? On reflection what do you think about the above matter?
Have you ever received a Penalty Notice from the Police?*
- Yes
- No
Please provide full details*
When did it occur? Please describe in detail the circumstances of the situation. Were there any other individuals involved? Could this situation occur again? If not, why not? On reflection what do you think about the above matter?
To your knowledge, are you named on any lists held by the Departments of Health or Education?*
- Yes
- No
Please provide full details*
When did it occur? Please describe in detail the circumstances of the situation. Were there any other individuals involved? Could this situation occur again? If not, why not? On reflection what do you think about the above matter?
Training/Support
A large proportion of our work involves the reading and writing of reports and communication logs.
Will you require any specific type of support with this aspect of work or during theoretical training?*
- Yes
- No
Please provide full details so that prior arrangements can be made*
Other Employment
To ensure compliance with the Working Time Regulations, we are required to obtain details of any additional employments.
Do you intend to work in other employment if successful in obtaining this position?*
- Yes
- No
Please provide full details, including hours worked and times of shifts if applicable*
Previous Experience
We would be very interested to hear of any personal experience you may have of caring for members of your family or friends, people in the community or patients in a hospital environments which you feel would be relevant to the job description.
Please provide details
Full or Part Time?*
- Full Time
- Part Time
*
- I understand that ALL Community Support Workers must be available, on a Rota basis, to cover alternate weekends OR one regular weekend day each week
Additional Notes (e.g. days off in the week following a working weekend)*
Holidays
Do you have any pre-booked holidays that we would need to approve?*
- Yes
- No
Please provide full details of all pre-booked holidays*
Declaration
Please read below carefully before signing this application.
1*
- I confirm that the enclosed information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.
2*
- I agree that upon commencement of employment the organisation reserves the right to require me to undergo a medical examination should this be necessary (Should we require further information and need to contact your Doctor for a medical report, you will be informed of this intention and written permission sought prior to contacting Doctor).
3*
- I agree that upon commencement of employment the organisation reserves the right to require me to undergo a medical examination should this be necessary (Should we require further information and need to contact your Doctor for a medical report, you will be informed of this intention and written permission sought prior to contacting Doctor).
I understand that the organisation is required to submit my details for an Enhanced DBS Check, or where applicable, carry out an on-line DBS update check and any discrepancy between that and the information I have provided could result in the termination of any employment contract offered.
Phone
This field is for validation purposes and should be left unchanged.

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Head Office

Mobile Care Services Ltd
Unit A
Abeles Way
Holly Lane Industrial Estate
Atherstone
Warwickshire
CV9 2QZ

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01827 715537 (4 lines 24/7)
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