Application Form Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Url Instructions Please read carefully before completing Please note that the form cannot be saved and must be completed in one sitting. Therefore, please make sure that you have all relevant information to hand including details and dates of all relevant education, experience and training. Some questions and sections of the form are conditional and are dependent upon your answers to previous questions. Some sections must be completed or you will not be allowed to proceed. Starred fields are mandatory. The application form has 7 pages. The final page has a submit button that will send the form through to us once pressed or clicked. A copy of the form in pdf format will be emailed to you Personal Information Position Applied For * Location * Please upload a passport sized photo of yourself * Title * Surname * Forename(s) * Any Previous Names Address * Town * Post Code * Email * Home Tel. No. Mobile Tel. No. * Are you legally eligible for employment in the UK? * Yes No Do you require a work permit? * Yes No Do you hold a current driving licence? * Yes No Have you access to a motor vehicle? * Yes No Education School/College/Further Education School/College/Further Education School/College/Further Education School/College/Further Education Qualification Qualification Qualification Qualification Year obtained Year obtained Year obtained Year obtained Other Information Employment and Experience Date From Date To Name and address of employer Job Title/Duties Date From Date To Name and address of employer Job Title/Duties Date From Date To Name and address of employer Job Title/Duties Date From Date To Name and address of employer Job Title/Duties Experience Please indicate your length of experience in each of the following client groups (in years and months): Adolescents Dom Care/Homecare Mental Health Rehabilitative Care Autism Respite Care Palliative Care Sensory Impairment Auxiliary/Hosptial Learning Disability Physical Disability Training Please indicate which of the following courses you have taken, You will also be asked if it is complete and if so, what year it was completed. Manual Handling/Hoist Training YesNo Infection Control YesNo Basic Life Support YesNo Food Hygiene YesNo Makaton YesNo Health and Safety Awareness YesNo Restraint Training YesNo Physical Intervention Techniques YesNo NVQ-2/3/4 YesNo Medication YesNo Dementia Awareness YesNo Mental Health Awareness YesNo Challenging_Behaviour_Management YesNo Experience, Knowledge and Skills Please tell us why you will succeed in this position, giving a brief outline of your experience and skills and how these meet the requirements of the enclosed job specification. You may also provide any other information that you think is relevant to this position. Experience, Knowledge and Skills References Provide four professional references for any past/previous employment. This may include educational references i.e. tutor or train instructor. Friends and family members are not acceptable referees Referee 1 Name Position Address Postcode Telephone Email address Relationship to Applicant Referee 2 Name Position Address Postcode Telephone Email address Relationship to Applicant Referee 3 Name Position Address Postcode Telephone Email address Relationship to Applicant Referee 4 Name Position Address Postcode Telephone Email address Relationship to Applicant Rehabilitation of Offenders Act 1974 – Notice to ex-offenders Due to the nature of the work you have applied for, you are exempt from section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act (Exemption Order 1975). This means that you are not entitled to withhold information relating to any convictions you may have had. Do you have any convictions to disclose? YesNo Please give a brief summary here. We will contact you should we require more information. This information will be treated as confidential in accordance with the Data Protection Act 1998. Health Screening This appointment will be subject to satisfactory completion of the Health Declaration overleaf. I declare that the information given is correct to the best of my knowledge and that omissions or false statements may disqualify me from employment or lead to dismissal. I will give Thorough Healthcare Solution Limited permission to contact referees or any previous employers. Tick the box to accept I Accept Date of Acceptance Personal Health Questionnaire Please tick if you are currently receiving treatment or have ever received treatment for: Asthma YesNo Eye trouble YesNo High Blood Pressure YesNo Recurring Chest Disease YesNo Back trouble YesNo Fainting attacks YesNo Mental Illness YesNo Recurring Headaches YesNo Deafness YesNo Fits or Blackout YesNo Muscle/Joint trouble YesNo Stomach Trouble YesNo Diabetes YesNo Heart Trouble YesNo Recurring Bowel trouble YesNo Shortness of Breath YesNo Do you have any medical condition which may affect your ability to work? YesNo Are you currently consulting a doctor about a specific condition? YesNo In the last three years, have you had any time off work for any health related reason? YesNo Inoculations Rubella YesNo Tetanus YesNo Hep B YesNo Polio YesNo Tuberculosis YesNo Varicella YesNo MRSA & COVID-19 Disclosure I confirm that to the best of my knowledge I am clear of MRSA or Covi1d 19 at present. Should I come into contact or have any suspicion that I may have come into contact with any person with MRSA or displaying symptoms of Covid-19. I will inform Thorough Recruitment limited immediately. I certify that I am in good physical and mental health. I declare that all information declared herein are true and correct to the best of my knowledge and that I have not omitted relevant details. I agree to inform you of any changes in my health and personal circumstances and that if false statements have been made, then it may result in the termination of my employment contract should my application process further. Print Name Signed Check to sign Date Signed