Helmar Care and Community Services
APPLICATION FORM
CONFIDENTIAL APPLICATION FOR EMPLOYMENT:
1. APPLICATION FORM
Position applied for
Date available to work
Payment requested
2. PREPARED TO WORK
Full Time
Part Time
Shift Work / 0 Hour
Contract
3. PERSONAL DETAILS:
First Name:
Middle Name:
Last Name:
Address:
Telephone Number(s) & E-Mail Address:
Work:
Home:
Mobile:
E-mail Address:
Do you own a car?
Yes
No
Have a current full
driving licence?
Yes
No
Provisional Licence?
Yes
No
HGC?
Yes
No
Yes No
Have you full endorsements?
If yes, please give details:
4. LANGUAGES (Which language do you speak?)
Do you speak or read any foreign language? (re: English)
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Helmar Care and Community Services
EDUCATIONAL BACKGROUND
5.
SECONDARY SCHOOLS
Names Schools, Addresses
Subjects, Examinations / Attainments
6.
FURTHER EDUCATION AND TRAINING
University/College
Type of Courses
Subjects
7.
OCCUPATIONAL QUALIFICATION
College/Institute or other name
8.
Qualification / Level
MEMBERSHIP OF PROFESSIONAL BODY
Name
9.
Level
EMPLOYMENT DETAILS
Present / Last Employer’s Name:
Address:
Job Title
Duties /
Responsibilities
Reason for leaving
Finishing Pay
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Qualification/Class/D
egree
Helmar Care and Community Services
Most recent employer
Address:
Duties and
responsibilities
Reason for leaving
Finishing Pay
Other most recent
Employer
Duties /
Responsibilities
Reason for leaving
Finishing Pay
10. GENERAL
Interests / Hobbies (past)
Office held for hobbies
Public duties held
If offered this position, will you continue to work in any capacity?
If ‘Yes’, please give details:
11. PERMISSION TO WORK IN THE UK
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Helmar Care and Community Services
Are there any restrictions to your residence in the UK that might affect your right to take up employment in the
UK?
Yes
No
If you are successful in your application, would you require permission to work in the UK?
Yes
No
12. COMMUNITY / VOLUNTEER EXPERIENCE
Name / Address of Organisation
Position / Title
Duties / Responsibilities
Applicants are requested to tick relevant boxes on a separate form to enable the organisation to monitor its
‘Equal Opportunities’ and ‘Inclusion’ Policies.
The monitoring is recommended by the Code of Practice for the elimination of racial discrimination and for the
elimination of discrimination on grounds of Sex and Marital Status.
The information given on the attached ‘Equal Opportunity’ Form is used for no other purpose and will be treated
as confidential.
13. RECRUITMENT POLICY: (Outcome 13 Regulation 22) focusing on the ‘Quality Care Commission’
(Reg. 2009; Registration and 2010; ‘Quality and Safety’ in Care Delivery of ‘Regulated Activities’
(Act, 2008)
13.1. Code of Conduct Policy: It is the organisation’s policy to employ the best qualified personnel with ability
to assess and monitor the quality of service delivery based on the ‘Essential Standards’ (Outcome 16/
Regulation 10) which requires competent Care Workers and Managers with capacity to enforce the
organisation’s policy on ’Person Centred’ which puts emphasis on ‘Equal Opportunities’ or which eliminates
issues of ‘Inequalities and Exclusion’ practices in ‘Health and Social Care’ provisions.
The management should ensure care workers observe their policy to provide the essential ‘Equal Opportunities’
for the advancement and promotion of ‘Social Inclusion’ and ‘Social Justice’ (Outcomes 1&2 / Regulations 17
&18); to combat discrimination of any person because of race, colour, ethnic origin, sex, sexual orientation,
religion or belief, pregnancy, trans-gender status, (Mental Health Act, 1983), civil partnership, social status, age
or disability.
13.2. Safeguarding Policy: It is the organisation’s policy to employ the best qualified personnel with the
capacity to observe the principles of ‘Safeguarding Vulnerable Adults’ re: protecting people who use APO Home
Care Service from Abuse (Outcome 7, Regulation 11).
CRIMINAL CONVICTIONS
Do you have any criminal convictions?
Yes
If Yes please give details on a separate sheet, this should exclude any spent convictions under
Section 4(2) of the Rehabilitation of Offenders Act 1974.
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Helmar Care and Community Services
To be completed by the applicant :
To be signed by the applicant :
Print your name:
Sign:
Date :
REFERENCE REQUEST FORM
PROSPECTIVE EMPLOYEE DETAILS
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Helmar Care and Community Services
Name of Candidate:
First Name:
Middle Name:
Last Name:
Date of Birth
Position applied for
Can you confirm the applicant worked for your company?
Yes
No
Please, provide applicant’s job title while working for your company
What were the
Full Time?
terms of work?
Reason(s) for leaving:
Part Time?
Start Date
Shift / 0 Hour Contract
Leaving Date
Did the applicant have any supervisory responsibility for any other staff?
Yes No
If ‘Yes’, what were the main duties and responsibilities (Please attach job description if you prefer):
ABSENCES AND HEALTH RECORD OF APPLICANT
Please comment on the applicant’s health record(s) during employment:
Please state the number of days and occasions of sickness in the last 12 months of employment (if
known):
Number of days
and occasions
Reasons
STANDARDS PERFORMANCE RATE
Please rate the candidate’s standards performance as follows:
General
Excellent
Good
Fair
Communication
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Poor
Helmar Care and Community Services
Quality of work
Dedication to the job
Ability to work
unsupervised
Initiative
Team work
Time Keeping
Trustworthiness
Where fair or poor performance has been indicated, please give details:
Did the applicant have any disciplinary warning during the last 12 months of
employment with your company?
Was the applicant ever the subject of any disciplinary action or had any
allegations of abuse towards a vulnerable adult made against her / him?
Yes
No
Yes
No
Yes
No
If ‘Yes’ to any of the questions, please give details (explaining the nature and the
outcome):
Please, comment on the applicant’s suitability for the post applied for:
Would you re-employ the applicant?
Print your name:
Sign:
Job Title:
Company Stamp:
Date:
Otherwise provide your company complement slip
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