Wycarleys

 

WYCAR LEYS RESIDENTIAL HOME APPLICATION FORM

CONFIDENTIAL

  1. Curriculum Vitaes are not acceptable.
  2. Please complete Part 1 to Part 5 in full.
  • PART 1 : PERSONAL DETAILS
  • PART 2 : JOB RELATED INFORMATION
  • PART 3 : EQUAL OPPORTUNITIES
  • Part 4 : PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE
  • Part 5 : EQUALITY & DIVERSITY MONITORING FORM

PART 1 : PERSONAL DETAILS
Residential home:
Post applied: A value is required.
Title:
Surname (current family name):
Forename(s):
National Insurance Number:
Present Address:
Post Code:
Previous Address (if you have lived at your present address for less than 12 months):
Address:
Post Code:
Are you subject to immigration control?
Are you free to remain and take up employment in the UK?
Are you subject to any employment restrictions?
If you are successful you will be required to present evidence of this prior to your appointment.
Home Telephone No:
Work Telephone No:
E-mail address:
Mobile Telephone No:
NMC Pin Number: (if applicable)
Expire Date:
Do you hold a current driving licence?
Please list any driving convictions:
Are you a friend or relative of (or have other links with) a Current/former employee or service user of Wycar Leys?
If yes, please provide their name and your relationship to them:
Have you ever worked for Wycar Leys?
If yes, please complete the following:
Your job title on leaving:
Name of home:
  Dates employed:
Date from:
Date to:
Was your contract terminated by the company?

PRESENT OR MOST RECENT EMPLOYER

Name of employer:
Employers address:
Date appointed:
Date of leaving:
Job title:
Earnings per annum:
Grade:
Notice required:
Reason for leaving:
Main duties:
How many days sick leave have you taken in the last two years?
Available to take up employment with effect from (date):
Are you prepared to work night shifts wherever required?

PAST EMPLOYMENT RECORD

(Please cover the last 10 years, starting with the most recent employer and explain any gaps in your employment. All dates provided must give a minimum of the month and year, however, full dates are preferable. If you have left school within the last 10 years, please put that down with dates so that a full 10 years is accounted for)

Please include;

  1. Name & Address of Employer
  2. Job Title
  3. Reason for Leaving
  4. Date To
  5. Date From
Past employment record:

EDUCATION

Please include;

  1. Name and Address of Schools / Colleges Attended
  2. Date From
  3. Date To
  4. Qualifications Obtained
Education:

REFERENCES

Two references will be taken after the interview, should you be successfully short-listed. Both should be from your two most recent employers. Otherwise you most recent employer and a character referee (non relative) will be acceptable as a second reference. If you have never been in paid employment, an academic referee along with a character referee will be acceptable.
Name:
Job title:
Work Relationship:
Organisation:
Full address:
Post code:
Tel No:
NB: The Company reserves the right to seek a reference from any previous employer, school, college, university, in addition to the preferred referees. However, we will not contact your referees until a provisional job offer has been made to you.
Name:
Job title:
Work Relationship:
Organisation:
Full address:
Post code:
Tel No:
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PART 2 : JOB RELATED INFORMATION

QUALIFICATIONS

Qualifications obtained from schools/colleges/universities including any relevant professional qualifications.

Please include;

  1. Name & Address of Establishment
  2. Dates
  3. Course Title
  4. Qualifications Received
Please note that you will be asked to furnish original copies of degree/professional level/or other relevant qualifications quoted on this application.

MEMBER OF PROFESSIONAL BODIES

RELEVANT TRAINING COURSES

Please state other relevant non-qualification courses you have completed, including short courses.

Please include;

  1. Dates
  2. Course Title

SKILLS AND ABILITIES

Please describe the qualities that you can bring to the job applied for.

KNOWLEDGE AND EXPERIENCE

(Gained through either paid work, voluntary work or life experience)

OTHER INFORMATION

(please continue on a separate sheet if necessary)

GENERAL HEALTH

Is your general fitness and mental health satisfactory for the position applied for?
If NO, please give details:
Have you been made subject to an order under any section in the Mental Health Act?
If YES, please give details:
NB you are also required to complete a pre-medical questionnaire.
Are you currently (in the UK or another country); suspended from duty, subject to an investigation by your employer or by any other body, subject to any police investigation and/or prosecution, or ever been disqualified from the practice of a profession?
Suspended:
If YES, please give details:
 

DECLARATION
Signature check box of applicant:
Declaration date:
By checking the above check box I hereby declare that the information provided on this form is correct to the best of my knowledge. I also give my consent to have this information held and processed by Wycar Leys in accordance with the Data Protection Act 1998.
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PART 3 : EQUAL OPPORTUNITIES
Wycar Leys is an equal opportunities employer and aims to ensure people are recruited, selected, trained and promoted on the basis of job requirements, skillm abilities and other objective criteria. The Company will ensure that no job applicant or employee receives less favourable treatment on the grounds of race, colour, nationality, ethnic or national origins, religious belief, sex, sexual orientation, marital status, disability, or is disadvantaged by conditions or requirements which cannot be shown to be justified as being necessary for the safe and effective performance of the job.
Declaration check box:
Declaration date:
By checking the above check box I declare that the replies given by me are true to the best of my knowledge and belief, and I give them knowing that I may be liable to subsequent dismissal from employment if I have wilfully given any reply which I know to be false or do not believe to be true. I also understand that any post offered is done so subject to suitable references being obtained and a successful Enhanced Disclosure Check from the Criminal Records Bureau being completed.
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Part 4 : PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE

Please read carefully before completing. The information contained within the completed questionnaire will remain confidential. However, Wycar Leys may disclose the data to its occupational health provider and any false information given may render you liable for summary dismissal.
Employee forename:
Employee surname:
Employee address:
Post code:
Position applied for:
Sex:

Occupational History:
Have you ever been advised for medical reasons not to do any particular kind of work?
Comments:

Past Medical History:

(please answer Yes/No if you have suffered from any of these conditions & give details if necessary)
Medical Condition Yes/No Details
Undue fatigue:
Bronchitis:
Breathlessness:
Allergies:
Pneumonia:
Hay fever:
Shortness of breath:
Jaundice:
Stomach problem:
Stomach ulcer:
Hernias:
Bowel problem:
Diabetes Mellitus:
Nervous disorder:
Dizziness:
Ear problem:
Hearing defect:
Epilepsy:
Eye problems:
Allergic reaction:
Rheumatic fever:
High blood pressure:
Low blood pressure:
Palpitations:
Heart attack:
Angina:
Asthma:
Chronic lung:
Stroke:
Heart murmur:
Back problem:
Joint problem:
Swollen legs:
Varicose veins:
Kidney:
Rheumatism:
Migraine:
Adverse reaction:
Glasses:
Skin conditions:
Alcohol:
Please detail any serious illness, hospital admission, operation or accident that has caused you to have 5 or more days off work in the last five years.
 

Specific questions:
  Yes/No Comment
Have you had any recent ill health?
Are you attending a hospital clinic or doctor at the present time?
Have you had Varicella (Chicken Pox)?
Have you had any other serious communicable disease? If so, please give details.
 

Inoculations:
  Have you been inoculated against the following:
  Yes/No Date
Diphtheria:
Hepatitis B:
Tuberculosis (BCG):
Rubella (German Measles):
Varicella (Chicken Pox):
Polio:
Tetanus:
Have you ever undergone a test for HIV?
Other – please specify:
 

Additional information:
    Details
Number of days sickness in the past year (ie in last 12 months)
Alcohol consumption per week in units (1 unit = 1⁄2 pint of beer or 1 glass of wine or 1 measure of spirits)
Do you smoke?
If yes, weekly tobacco consumption
Cigarettes:
Roll ups:
G.P.’s Name:
G.P.’s address:
G.P.’s Telephone No:
 

Consent & Declaration
Consent check box:
Consent date:
  1. By checking the above check box I declare that the information I have given on this document, is to the best of my knowledge, a true and complete account of my medical history.
  2. I consent that this information may be held and processed by Wycar Leys Ltd under the Data Protection Act 1998.
  3. Further to the company’s risk assessment on infectious diseases, it has been identified that it is necessary from a health & safety perspective that all staff are vaccinated against Hepatitis B, for both their own safety and the safety of our service users.
  4. I understand and accept that should I be employed by Wycar Leys, it will be a condition of my contract of employment to be fully immunised (if not already) against Hepatitis B, within the first three months of employment and remain regularly immunised.
  5. I understand and accept that if I do not comply with the above obligations or should any information come to light following my employment with Wycar Leys Ltd which shows that medical information disclosed by myself was misleading or false, Wycar Leys Ltd may terminate my employment.
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Part 5 : Equality & Diversity Monitoring Form

Wycar Leys strives to operate a policy of equality and diversity and not discriminate against any person. The information you provide will be treated in the strictest confidence and is for monitoring purposes only and in no way forms any part of the selection process.
Ethnic Origin:
Gender:
Hours of post:
Age group:
  Please select that which best describes your sexuality:
Sexual orientation:
  Please indicate your religious belief:
Religious Belief:
Marital Status:

Disability Discrimination Act 2005

A person has a disability under the Disability Discrimination Act if he/she has a physical or mental impairment which has a substantial and long term adverse effect on his/her ability to carry out normal day to day activities. Long term means has lasted, or is expected to last, for 12 months. Do you consider yourself to be a disabled person?
Disability discrimination:
  If answering yes, please give details of your disability:
Disability discrimination details:
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