Application Form

Confidential

PLEASE ENSURE YOU FILL IN ALL SECTIONS

Post applied for: Which business? Where did you see this post
 Agincare UK branch; state advertised? (circle)
location:
 Care Homes; state name:
 Agincare Live-In Care state
whether ALIMS or
Operational company
(SW/SE/C):
 Head Office Function
 Agincare Support Services
 Training Now
Job Centre / Total jobs /
Agincare Website /
Newspaper / Friend /other
Name of
friend:_________________
Other: ________________

1. Personal Details and Information (to be completed in block capital please)

Surname: Title: Mr / Mrs / Miss / Ms (delete as appropriate)

Forenames: NI No.

Address:

Postcode: Email:

Home Tel No.(inc code): Mobile Tel No:

2. Additional Information
Do you possess a valid driving licence for Do you have use of a car for work? (please circle)
the UK? (please circle) Yes / No Yes / No
Do you have the legal right to work in the UK? (please circle) Yes / No
If ‘Yes’ but there are conditions attached, please specify (e.g. start/finish dates/WRS etc.):

If ‘No’, please note we are unable to recruit anyone who does not have the legal right to work in the UK.

Are you related to or do you know anyone who works for Agincare? (please circle) Yes / No
If ‘Yes’ please give the name of the employee and the relationship to them.

Do you have any other work commitments, either paid or unpaid, which you would wish to continue with if
offered employment by Agincare? (please circle) Yes / No (if yes, please advise details at interview)

QP107/2Forms /Iss15/v1
3. Criminal Record Declaration
The nature of the work you are applying for is exempt from the provisions of the Rehabilitation of Offenders
Act 1974. If you are applying for a post involving access to persons in receipt of care services, your offer of
employment will be subject to a satisfactory enhanced Disclosure and Barring check. It is therefore a
requirement that all previous convictions are declared, even those which would otherwise be regarded as
‘spent’. (Any such information will be treated confidentially).

The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are
'protected' and are not subject to disclosure to employers , and cannot be taken into account.

Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and
Barring Service website.

Please read the above carefully and then answer the following questions:
Have you ever been convicted of a criminal offence? (please circle) Yes / No
Have you ever received any official cautions, reprimands or warning? (please circle) Yes / No
To your knowledge, are you currently the subject of any criminal proceedings or any police investigation?
(please circle) Yes / No
If you have answered yes to any of these 3 questions please provide details below:

4. Education, training, qualifications and current learning

(Please ensure you include all dates and do not leave any gaps in history)

Secondary education: Qualifications/grades/date obtained:

Further/higher education Qualification/grades/date obtained:

Other relevant training, professional qualifications or work related skills (including dates)

2
QP107/2 Form/Iss15v1
Any details of membership to professional bodies (please provide details including any offices held)

5. Employment History
Current/most recent employment
Employer’s Name: Start date: End date:

Address:

Postcode: Tel. No.

Job Title: Final pay / salary:

Reason for leaving if applicable:

Brief description of duties and responsibilities:

Full Employment History (most recent first with any gaps explained) please continue of an additional
sheet if required
Dates Job Title Employers Name and Address Reason for
From To Leaving
mm/yy mm/yy

3
QP107/2 Form/Iss15v1
6. Relevant Experience

Please use this section to state how your skills, experience and training would enable you to meet the
requirements of the role for which you are applying. Please make reference to the person specification.
Please use a continuation sheet if necessary.

4
QP107/2 Form/Iss15v1
7a . AVAILABILITY (only complete this section if you are applying for a CARE Worker position
Morning shift Afternoon shift Evening shift Sleep Nights Wakeful Nights
Weekdays
Saturday
Sunday
7b. AVAILABILITY (only complete this section if you are applying for Live-in Care Services Care
worker position). Please state your preferred work pattern ( e.g. Two weeks on two weeks off /Four week,
one week off etc If you are flexible then state this.)

Geographical area /specific counties you are interested in working? Please note the more flexible you
are with location, the easier it may be to place you e.g. in Live-In Care

Type of work you are interested in (delete as appropriate) Care / Domestic / office/maintenance / other –
please state

If this is a flexible working post, what is the ideal number of hours you would like to work per
week?:

8. References
Please provide the names and contact details of referees: the first two must be your present or
most recent employer and most recent previous employer, if there is less than two years between
both of these then please provide a further references. We will not contact any referee without your
permission or until an offer of employment has been accepted. If you do not have three employment references, one may
be from a professional body, a lecturer or teacher or similar. Also, if you have previously been employed in a position
which involved working with vulnerable adults or children then one of the references you provide must be from this
agency/employer (in accordance with the Health and Social Care Act 2008).

Personal referees such as relatives, friends, neighbours etc ARE NOT acceptable as referees
1. CURRENT OR LAST 2. PREVIOUS EMPLOYER 3. PREVIOUS EMPLOYER
EMPLOYER
Company Name: Company Name: Company Name:

Referee’s name and position: Referee’s name and position: Referee’s name and position:

Address: Address: Address:

Postcode: Postcode: Postcode:

Tel no: Tel no: Tel no:

Fax no: Fax no: Fax no:
Email address (not a personal Email address: Email address:
email address):

Relationship to you (e.g. manager Relationship to you (e.g. Relationship to you (e.g. manager
/ supervisor) manager / supervisor) / supervisor)

Reason for leaving: Reason for leaving: Reason for leaving:

Can referee be contacted prior Can referee be contacted prior Can referee be contacted
to interview YES/NO to interview YES/NO prior to interview YES/NO

5
QP107/2 Form/Iss15v1
9. Applicant Declaration (Please read carefully before signing the application)

1) The information in this form is true and complete. I agree that any deliberate omissions, falsification or
misrepresentation on this form will be grounds for rejecting this application or subsequent dismissal if
employed by the organisation. This equally applies to any medical questionnaires or falsified documents I
may provide.

2) I confirm that I have not been subject to any cautions or convictions (other than those given above),
investigation, disciplinary action, or enquiry into adult/child protection matters or inappropriate behaviour,
and that the information I have given in the Criminal Record declaration section is to the best of my
knowledge correct.

3) The Company is required to tell you about the personal data that we collect about you and what we do
with that information, including how we use, store, transfer and secure your personal data. . Your
application will be kept on file for a period of 12 months should you be unsuccessful, should you be
successful then this will remain on your staff file for duration of employment. Your file will be retained as
per Company guidelines which are found within the Confidentiality, Data Protection and disclosure Policy.

4) You confirm that you shall at all times comply with all relevant data protection legislation and all obligations
imposed on you under the Company's data protection policy and privacy notice

Name (please print): ................................... Signed: .................................... Date..............

What happens now:

 If you wish to return this application by post please do send to the service address.
 If you have downloaded this application form please email to [email protected]
 You are able to return this application form to any of our branches, offices or care homes a full list of
addresses can be found at www.agincare.com
 If you have not received any correspondence within 14 days then please assume on this occasion you
have been unsuccessful, and your application form will be kept on file for 12 months.

The information provided by you on this form may be processed for purposes permitted by the General Data
Protection Regulation. You have, on written request, the right of access to personal data held about you. The
company treats personal data collected during the recruitment process in accordance with our Data Protection
Policy.

Thank you for your application

6
QP107/2 Form/Iss15v1