Application Form Application Form Position Applied ForPlease select...Care AssistantSenior CarerHousekeeping/LaundryMaintenanceCookOtherHome Applied for*In which home are you applying to work?Please select...SouthsideHolly HouseKarenzaThe BeechesWhich homes would you be willing to work in?Please tick which homes you are able to travel to for work. Southside (Hall Green, Birmingham) Holly House (Acocks Green, Birmingham) Karenza (Rowley Regis, Birmingham) The Beeches (Rowley Regis, Birmingham) Are you currently working?*YesNoWhat is your notice period?How much notice will you need to give your current employer, or when will you be available to start work with us?Will you continue in any other employment?*If you obtain this position, will you continue in any other employment?YesNoDetails of other employmentPlease give details of any other jobs, including the hours you will work there and whether we will need to schedule your shifts around another job.Is your ability to perform this job limited in any way?*YesNoDetails of LimitationsPlease give details of your limitations, including how we could help you to overcome them.Special Requirements*Do you require any special arrangements during the recruitment process, e.g. large print forms or additional time?YesNoDetails of Special ArrangementsPlease give details of all special arrangements required.Restrictions to capacity to work in the UK*Are there any restrictions to your residence in the UK or working permissions, e.g. a time limited work permit or restrictions to the number of yours you can work?YesNoDetails of UK work restrictionsPlease give further details of any restrictions to your residence in the UK or working permissions.Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneMobile PhoneEmail* Do you have a full and current driving license?*YesNoDo you have any penalty points, convictions or restrictions on your license?YesNoLicense DetailsPlease list all penalty points, convictions and restrictions on your license, including any relevant dates.AbsencesPlease list any absences from work (other than annual leave) during the past 12 months.Reason for AbsenceLength of Absence How many hours per week would you like to work?*Which shifts are you available to work?*Tick all shifts that you're willing to work. Days (8am to 8pm) Nights (8pm to 8am) RestrictionsPlease list any days or hours during the week which you CANNOT work. If you leave this blank then we will assume that you are available 7 days per week. Employment HistoryDo you have a CV?*Tick yes if you have an up to date CV, cover letter or any other document you want to submit with your application.YesNoCV UploadUpload CV, cover letter or any other documents to support your application. Drop files here or Does your CV contain a complete and up to date work history?*YesNoEmployment historyPlease list entire employment history Name of EmployerStart DateLeave DateDutiesReason for Leaving How many years experience do you have working in Care?*How many years experience do you have working with people with Dementia?*How many years experience do you have working with people with Challenging Behaviour?*How many years experience do you have working in a Senior Role?*Qualifications and TrainingDoes your CV contain details of all your qualifications and training?*YesNoQualificationsPlease list all qualifications you hold, including GCSE, A-Level, Degrees, Diplomas, NVQ/QCF and any others you deem relevant. QualificationDate CompletedResult/Grade TrainingPlease list all relevant training you hold.Training CourseDate CompletedDate of Expiry (if applicable) NVQ/QCF Level*If you hold an NVQ/QCF or similar vocational qualification, please select which level you hold.NoneLevel 2Level 3Level 4Level 5ReferencesEmployment ReferencePlease give details of your most recent previous employer, and any other employers from whom we can obtain a reference.Employer NameSupervisors NameEmail AddressAddressPhone Number Character ReferencePlease give details of at least one responsible person who is not related to you and is over 18.NameRelationship to youEmail AddressAddressPhone Number Criminal Records CheckWorkers of The Home are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions. Please note, you may not be eligible for work in a care setting if you are on the DBS Register(s). Do you have any criminal convictions, charges, warnings or cautions to declare?*Declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.YesNoCriminal ConvictionsPlease list all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions below.ConvictionDateFurther Details SIGNATURE and DECLARATION – IMPORTANT – READ BEFORE SIGNING*I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately. I understand that I may not be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise JW Care Group to request a DBS Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status. Declaration read and understood Do you have any more information to provide in support of your application?