Please Complete in Block Capitals

4 Frecheville Court Glenmore Street Bury BL9 OUF

0161 761 0035 PLEASE COMPLETE IN BLOCK CAPITALS

Position: Support Worker Date:

Surname : First Name :

Date Of Birth : Telephone :

Marital Status : Mobile :

Address :

Next Of Kin (Name and Address, telephone number and state the relationship to applicant)

Do you have a valid driving licence and have Nationality: access to a car: National Insurance no: Work Permit Required:

Relevant Experience: (paid or unpaid)

Training undertaken Date of completion of Expiry date (if applicable) Copy of certificates retained course on file NVQ 2

Moving & Handling

Medication (level 2)

Food Hygiene

Other (please specify) Morning shift (from 7am to 2pm Approx) Afternoon shift(from 3pm to 10.30pm Approx) MON TUES WED THUR FRI SAT SUN Hours available for work shift:

WHAT IS YOUR AVAILABLILTY FOR WORK AT THE WEEKENDS (you must be able to work alternative weekends)

EMPLOYMENT HISTORY

(MUST be fully dated MONTH and YEAR, Care Quality Commission requires a full employment history and educational establishments attended since leaving school, all addresses must be detailed also)

Name and address of present Employer Position Held Duration Reason For Leaving

Month: Year:

Month: Year: Name and address of previous Employer Position Held Duration Reason For Leaving

Month: Year:

Month: Year: Name and address of previous Employer Position Held Duration Reason For Leaving

Month: Year:

Month: Year: Name and address of previous Employer Position Held Duration Reason For Leaving Month: Year:

Month: Year: Please continue on a separate sheet if needed References – Give details of three professional referees, one must be a recent employer

Name: Address :

Profession of the Referee: Postcode: Professional or Character Reference: Telephone (include mobile) Email address:

Name: Address:

Profession of the Referee: Postcode: Professional or Character Reference: Telephone (include mobile) Email Address:

Name: Address:

Profession of the Referee: Postcode: Professional or Character Reference: Telephone (include mobile) Email address:

‘Do you have any convictions, cautions, reprimands or final warnings that are not "protected" as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198’.

Please give details below (If none, please state none)

Have you ever been dismissed, suspended or been subject to disciplinary proceedings received in previous employment? If yes, please give details EMPLOYEE MUST GIVE THE COMPANY FOUR WEEKS NOTICE IN THE EVENT OF LEAVING THE POST APPLIED FOR

I HAVE APPLIED FOR A POSITION WITHIN THE COMPANY AND ALL INFORMATION GIVEN IS ACCURATE TO THE BEST OF MY KNOWLEDGE, AND TERMS OF EMPLOYMENT HAVE BEEN EXPLAINED AT INTERVIEW. Any information which may be discovered after employment has commenced, which contravenes terms of employment, will result in termination of position with EasyCare Ltd.

Underneath to be signed at the interview and witnessed by Company Manager.

SIGNED______

DATE______

CONFIRMED BY______

TRAINING AGREEMENT

In consideration of the training which I will be receiving from Easycare Ltd, I agree to remain employed by Easycare for a minimum period of one year after completion of the training.

This training will be completed within 3 months from my employment commencing with the Company and if I leave my employment at any time before the end of the following one year after completion of training then I undertake to refund to my employer £ 116.82 or a proportion based on the following scale:-

Less than 3 months after completion of training 100%

3 months but less than 6 months after completion of training 75%

In the event of my failure to pay I agree that my employer has the right as an express term of my Contract of Employment to deduct any outstanding amount due under this agreement from my salary or any other payments due to me on the termination of my employment in accordance with the legislation currently in force.

Signature ......

Date ...... PAYMENT OF THE CRIMINAL RECORDS BUREAU CHECK

DUE TO THE REQUIREMENTS OF THE POST STATING THAT THE PROSPECTIVE CANDIDATE MUST HAVE A CRB CHECK COMPLETED HEREBY I GIVE MY AGREEMENT AND AM PREPARED TO MAKE FULL PAYMENT PRIOR TO COMMENCING MY EMPLOYMENT WITH EASYCARE.

Please sign below

Name......

Signature......

Date......

NEW START DETAILS

THIS FORM COMPLETED WHEN APPLICANT IS SUCCESSFUL Name of Bank:

Address (inc Post Code):

Account Number:

Sort Code:

Roll Number (If Applicable):

To be completed by staff member once an employment offer has been confirmed

Print Name______

Signed______

Date______

Confirmed By______