Please fill in all sections of this application form. If you complete the form in Word, save it to your PC, fill in the blanks, and return it to Alison via Alison.Hamlin@kembleathome.co.uk. Otherwise, please use black ink.

Position

Are you applying for a live-in care or visiting care (support by the hour) role?

Personal details

Surname
First Name
Have you ever had another name? Yes/ No. If yes, what is it?
If yes, please state
Address
Postcode
Daytime telephone no.
Evening telephone no.
Mobile no.
Email Address
National Insurance No.
Do you have a valid driving licence? Yes / No
Do you have penalty points (if yes, how many)
Do you have use of a car for work Yes / No
Name of your Motor Insurance Company (Remember, you will need to be insured for business use on your policy, as you will be using your vehicle for work. You will also need to ensure business cover includes carrying passengers)

Current Employment

Position Title
Date Started
Date Left
Employer’s Name
Address
Postcode
Email Address
Notice Period
Brief outline of duties
Reason for leaving

Previous Employment

Please list ALL of your previous jobs including any with your present employer. Start with the most recent. References may be sought from your previous employers. If necessary please continue on a separate sheet, placing your name in the TOP RIGHT corner and numbering the additional sheets.

Job Title
Date Started
Date Left
Employer’s Name
Address
Postcode
Brief outline of duties
Reason for Leaving
Job Title
Date Started
Date Left
Employer’s Name
Address
Postcode
Brief outline of duties
Reason for Leaving
Job Title
Date Started
Date Left
Employer’s Name
Address
Postcode
Brief outline of duties
Reason for Leaving

Job Title
Date Started
Date Left
Employer’s Name
Address
Postcode
Brief outline of duties
Reason for Leaving

Breaks in employment history

Any gaps in employment history since leaving school and reasons must be detailed below; this should include voluntary work, unemployment, domestic reasons, prison custody etc. If necessary, please continue on a separate sheet, placing your full name in the TOP RIGHT corner and numbering the additional sheets.

From	To
Reason
From	To
Reason
From	To
Reason

References

Please give details of three referees (two ideally being previous employers) whom we may ask about your suitability for the job. THE FIRST REFEREE MUST BE YOUR CURRENT OR MOST RECENT EMPLOYER (or school if you are a school leaver) but we will not request a reference without your consent. You should not name a relative as a referee. We reserve the right to contact any other previous employer for a reference.

Referee 1 – Current or most recent Employer
Name
Address
Postcode
Telephone no.
Email Address
Job Title
Is this referee an Employer or a friend?
Can we contact this referee prior to interview?
Referee 2
Name
Address
Postcode
Telephone no.
Email Address
Job Title
Is this referee an Employer or a friend?
Can we contact this referee prior to interview?
Referee 3
Name
Address
Postcode
Telephone no.
Email Address
Job Title
Is this referee an Employer or a friend?
Can we contact this referee prior to interview?

Educational qualifications

Please give details of secondary, further and higher education qualifications achieved. Start with the most recent. Please include institute details e.g. college etc. Please bring your certificates to any interview. If necessary, please continue on a separate sheet, placing your name in the TOP RIGHT corner and numbering the additional sheets

Office Use
Date	Qualification Name (gained or pending)	Institute/ Certifying Body	Grade Obtained	Certificates Checked by (initial)	Date Checked

Training

Please list relevant job-related training you have undertaken, and/or any professional qualifications achieved. Bring your certificates to interview. If necessary, please continue on a separate sheet, placing your name in the TOP RIGHT corner and numbering the additional sheets

Office Use
Date	Course Title (previous / current)	Organizer	Certificates Checked by (initial)	Date Checked

Disciplinary Matters

Have you been subject to any disciplinary or action including suspension from duty during your periods of employment with any employer? Yes / No

Include any investigations or actions taken by your professional body.

If YES, please provide dates and details of action taken below. Include any pending incident/action.

Further information

Please give any information below that you think will help us to consider your application and tell us a little about yourself. You should relate this to the Notes for applicants wishing to be considered as Care Assistants. Also include relevant experience, specialised knowledge, voluntary work and any leisure interests and hobbies. If necessary, please continue on a separate sheet, placing your name in the TOP RIGHT corner and numbering the additional sheets

Criminal convictions/cautions/disqualified persons/investigations

We are committed to the welfare and safety of vulnerable adults and so successful applicants will be required to undergo an enhanced Disclosure and Barring Service (DBS) check. Criminal convictions are not necessarily a bar to employment but the safety of our clients will be key to our decision.

This position is exempt under the Rehabilitation of Offenders Act 1974; therefore, you must disclose any unspent convictions, cautions, reprimands or warnings.

To assist with the implementation of this policy, all applicants are asked to complete the following questionnaire and provide written consent for checks to be completed.

Referee 2
Have you ever served a custodial sentence?
Have you ever pleaded guilty or been convicted (within the last 11 years) or been cautioned by a police officer for any criminal offence, within the last 6 years? If you have more than one conviction, you must tell us about ALL of them, regardless of how long ago.
Have you ever been interviewed as a potential suspect or investigated in relation to matters that might have led to criminal proceedings.
Have you been subject to, or interviewed, in relation to disciplinary matters or allegations against you, in any previous employment?
Have you been subject to, or interviewed, in relation to disciplinary matters or allegations against you, in any previous employment?
Has your name been added to either of the two lists of people barred from working with children and/or vulnerable adults under the Safeguarding Vulnerable Groups Act 2006?
Have you ever been subject to, or party to, court proceedings, involving any social services authority or its equivalent, here or abroad, that has resulted in the removal of children or vulnerable adults from your care, or the imposition of a statutory supervision order?
If the answer to any of these questions is YES, please give full details on separate sheet
Have you ever been refused registration or cancelled from any official registers of: Child-minders, Day Care Providers, Private Fostering, Registered Care Home or Children’s Home?
You are reminded that knowingly withholding this information or failing to disclose subsequent information may lead to an application for employment not being approved. You should note that it is an offence to knowingly apply for, offer to do, accept or do any work with vulnerable adults when prevented by reason of inclusion in either of the Lists created under the provisions of the Safeguarding Vulnerable Groups Act 2006.

Agreement to disclosure

I hereby give consent to Kemble at Home completing such checks as are necessary in order to verify the information provided above.

I further understand and agree that if, for whatever reason, my application is either refused or withdrawn, but information is revealed which leads the company to conclude that I may pose a risk to vulnerable adults, it will keep this information for an appropriate period.

If you take up employment it is necessary for you to inform the person with personnel responsibilities of any cautions, bind over orders or convictions you sustain during the subsequent course of your employment.

Failure to do so will lead to a disciplinary investigation or an application for employment not being approved.

Name:
Signature:
Date:

Personal relationships to employees or clients of Kemble at Home

Please give the details of any employee or client whom you know personally (this includes family and friends). If necessary, please continue on a separate sheet, placing your name in the TOP RIGHT corner and numbering the additional sheets.

Name 1	Relationship
Name 2	Relationship
Name 3	Relationship
Name 4	Relationship

Hobbies, sports and interests

Please list below any hobbies, sports or interests:

Declaration

I certify that to the best of my knowledge the details provided on this form and all other supporting papers are true and correct. I understand that if I have provided false or misleading information or omitted relevant information, this will result in the termination of any contract of employment or the withdrawal of any offer of employment.

In accordance with the Data Protection Act 1998, the information or data which you have supplied on this form may be processed and held on computer, and will also be processed and held on your personnel record if you are appointed. The data may be processed by this organisation for the purposes of equality monitoring, compiling statistics, and for the keeping of other employment records. By signing and returning this application form you will be deemed to be giving your explicit consent to processing of data contained or referred to on it, including any information which may be considered to be sensitive personal data.

Name:
Signature:
Date: