Application Form

Job role: Care Assistant

Please circle appropriate answers

Title: Mr/Mrs/Miss/Ms Surname: AKTER

Forenames: MUMINA Surname from birth:

Date of Birth: 18 JUNE 1996

Place / Town of Birth: MOULVIBAZAR

Present Nationality: BANGLADESHI Country of Origin: BANGLADESH

Nationality at birth: BANGLADESHI

National Insurance Number:

National Insurance Category: Full Reduced Exempt

Full Address: SHAMERKUNA, MOULVIBAZAR SADAR, MATHARKAPON,

MOULVIBAZAR

Postal Code: 3200 Telephone No (home): +88 01788683675

Time at Address (If less than 5 years then give previous addresses up to 10yrs): from Birth

Mobile Telephone No.: +88 01788683675

Email address: [email protected]

Care Direct & Support Solutions Ltd | R/O 18 Bloomfield Avenue, Luton, Bedfordshire, LU2 0PS | Email: [email protected] |
www.caredirectandsupportsolutionsltd.co.uk | Tel: 01582 725 998/079 326 59527/078 603 805 94 | CQC Regulated|Company reg: 09892365

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Next of Kin Details (to be notified in the case of an emergency)

Name: A. MOHIT

Address: DAISHAR, RAJNAGAR, BALISHAHASRA-3200, MOULVIBAZAR

Telephone No.: +88 01747920018 Relationship: SPOUSE

Experience and Qualifications: (to enable us to place you, please tick what experience you have)

Bath/shower/strip wash  H.D.U

Use of bath aids  C.C.U
Mouth care inc. denture care  Recording respiration
Care of feet  Weight Chart 
Dressing/undressing  Recording Pulse 
Bed bath  Urine Testing
Shaving Obtaining sample specimens
Care of hair  Preparation of meals 
Care of fingernails  Feeding Patients 
Care of eyes  Pressure area care
Care of bladder and bowels Ensuring medication has been taken 
Use of bedpan/commode  Observing changes in patients/clients and reporting 
Emptying catheter bags  Simple dressing 
Changing colostomy bag colostomy Experience of caring for the terminally ill 
Recording fluid balance Experience in milk kitchens/bottle feeding 
Moving and handling patients colostomy Assisted with return of patients from operating theatres 
Use of walking aids  Assisted with occupational therapy inc. sport and play 
Use of a hoist  Answering the telephone, taking, recording and 
Current moving and handling courses  conveying messages 
Recording blood pressure  Bed making 
Recording temperature  Changing a bed/drawsheet with patient on/in it 
Care of neonatal  Lighthouse work, washing personal laundry 
Portering  Shopping/collecting pension 
Circulating Experience with dementia
Sterile services Care of paediatrics
I.T.U

Any other experience that you feel may be relevant please state below:

Health Care Assistant,

The Royal (Pvt) Hospital
Sreemangal road, Berirpar, Moulvibazar
Mobile: +88 01719695032

Please give details and provide copies of any certificates that may be relevant to the position you have
applied for:

Care Direct & Support Solutions Ltd | R/O 18 Bloomfield Avenue, Luton, Bedfordshire, LU2 0PS | Email: [email protected] |
www.caredirectandsupportsolutionsltd.co.uk | Tel: 01582 725 998/079 326 59527/078 603 805 94 | CQC Regulated|Company reg: 09892365

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Education

Name and Address of Secondary Date when taken Grade/Mark (e.g. GCSE,
School/Colleges attended Diploma, HNC Etc)
Bachelor of Social Science (Honours)
Moulvibazar Mohila College
May 25, 2022 CGPA= 2.91 out of 4.00
Under National University
Bangladesh
Higher Secondary Certificate
Examination-2016
August, 18, 2016 GPA = 3.17 out of 5.00
Moulvibazar Govt. Women’s College
Under Sylhet Education Board
Secondary School Certificate
Examination-2013
May 09, 2013 GPA = 3.31 out of 5.00
M.Israil A.M.Amir High School
Under Sylhet Education Board

Training
Please gives details of relevant training completed

CARE CERTIFICATE (STANDARDS 1 TO 15)

Complete Date:
From: Caredemy, online skills for care

Http://caredemy.co.uk

Work Experience
Please give details of all your employment. If there are any gaps please specify why?

Name and Address of Employer Position Held Date from Date to Reason for leaving

THE ROYAL (PVT) HOSPITAL

Sreemangal road, Berirpar, Health Care
Moulvibazar 01/05/2022 31/03/2023 Going Aboard
Assistant
Mobile: +88 01719695032
E-mail: [email protected]

Work Preferences

Full Time  Part Time Weekends Weekdays Nights Occasional Weekends

When are you available to work?

General information

Do you hold a current full driving licence? Yes No 

Do you own your own transport? Yes No 

If yes then please specify:

Care Direct & Support Solutions Ltd | R/O 18 Bloomfield Avenue, Luton, Bedfordshire, LU2 0PS | Email: [email protected] |
www.caredirectandsupportsolutionsltd.co.uk | Tel: 01582 725 998/079 326 59527/078 603 805 94 | CQC Regulated|Company reg: 09892365

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Do you speak any other language as well as English? Yes No
If Yes then please specify: Bengali

If you are married please state the date & place of marriage: 24/08/2022, Moulvibazar

Have you ever worked night shifts in the past? Yes  No

What type of work was this? Patient care

Have you ever suffered health problems directly relating to working night shifts? Yes No 
(if yes please specify)

Rehabilitation of Offenders Act 1974 and Criminal Records

By virtue of the Rehabilitation of Offenders Act 1974 (exceptions) (amendments) order 1986, the provision
of a section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is
concerned with the provision of health services and which is of such kind to enable the holder to have access
to persons in receipt of such services in the course of his/her normal duties. You should therefore list all
offences on a separate sheet even if you believe them to be “spent” or “out of date” for some other reason.

Have you ever been convicted of a criminal offence? Yes/No 

Have you ever been cautioned or issued with a formal warning for any criminal offence? Yes/No 

(If you have answered “Yes” please attach details including dates on a separate sheet.)

CRB. The Criminal Records Bureau is the executive agency of the home office responsible for conducting
checks on criminal records. We are a registered body for receipt of CRB disclosure information. NHS Trust
and Private Sector hospitals and nursing homes insist on agencies making informed recruitment decisions,
which require criminal record checks to be made on all staff. It is a condition of proceeding with your
application hat you apply for a CRB disclosure (or that you produce an acceptable original disclosure which
you have already obtained). The Disclosure will be compared with the information given above and any
inconsistencies could invalidate your application or lead to the cancellation of your registration with us.

Signed Date

Do you require a work permit or other permission to take employment in the U.K. Yes  No
(if yes please complete below)

Work Permit: Yes No  Expiry Date:

Passport Nationality: BANGLADESHI Place of Issue: DIP/DHAKA

Passport Number: A03844475 Date of Issue: 07 MAY 2022 Expiry Date: 06 MAY 2032

Working Time Directives

The European Union has laid down guidelines for all workers, governing the length of maximum working
week that is safe to work. The current limit is 48 hours per week. Because you are under no obligation to

Care Direct & Support Solutions Ltd | R/O 18 Bloomfield Avenue, Luton, Bedfordshire, LU2 0PS | Email: [email protected] |
www.caredirectandsupportsolutionsltd.co.uk | Tel: 01582 725 998/079 326 59527/078 603 805 94 | CQC Regulated|Company reg: 09892365

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accept work offered, you will never be compelled to work more than 48 hours per week but you may choose
to do so.

Please would you sign below to confirm that you have read and understood this information, indicating your
preference by ticking the most appropriate statement.

I DO NOT wish to work more than 48 hours per week.

I DO wish to work more than 48 hours per week.

Signed Date

Data Protection Act 1998 and Inspection

Part of the care standards commission inspection process involves checking that we maintain certain
information on staff e.g. address, qualifications, a mechanism for checking health and fitness including
records of immunisation, record of training, annual leave and sickness, two written references and
rehabilitation or Offenders information. Inspectors will need to know that the company in maintaining the
information as we should; please be assured that they will not wish to read personal information such as
supervision notes.

We would be grateful if you would complete and sign the declaration below. If you have any concerns about
this or want to discuss it further, please contact Care Direct & Support Solutions Ltd.

I consent  I do not consent

Name: MUMINA AKTER

Sign: Date:

References

Please give the names of two professional people or senior/grade position to you, including your present or
most recent employer whom we may approach for a nursing reference (not relatives or friends). They must
be able t provide a credible comment on your ability to undertake the duties of the post applied for.

Home addresses of referees are not acceptable.

Reference 1
Name: MD. FAHAD ALOM
Position: Managing Director
Work Address: The Royal (Pvt) Hospital
Sreemangal road, Berirpar, Moulvibazar, Bangladesh.

Postal Code: 3200

Telephone No: +88 01719695032
E-mail: [email protected]
Care Direct & Support Solutions Ltd | R/O 18 Bloomfield Avenue, Luton, Bedfordshire, LU2 0PS | Email: [email protected] |
www.caredirectandsupportsolutionsltd.co.uk | Tel: 01582 725 998/079 326 59527/078 603 805 94 | CQC Regulated|Company reg: 09892365

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How long have you known this person? One and half year
In what capacity does this person know you? I was doing my Healthcare Job

Reference 2
Name: MD. ABDUL AWAL
Position: Assistant Professor,
Department of Sociology
Work Address: Moulvibazar Govt. Women’s College
Moulvibazar,
National University, Bangladesh.
Postal Code: 3200
Telephone No: +88 01714-608698
E-mail: [email protected]

How long have you known this person?

In what capacity does this person know you?

Declaration

The information that I have given in this registration form is to the best of my knowledge, complete and
accurate in all respects. I understand that knowingly giving false information will disqualify me from
registration with this agency. I also agree to keep Privileged Care Direct & Support Solutions Ltd advised of
any changes to any information.

Name: MUMINA AKTER

Sign: Date:

If invited for an interview, please ensure you supply original and photocopies of the following:

Two passport sized photographs

Proof of identity (birth/marriage cert. New style driving licence/passport)
Copy of work permit, visa stamp, entry stamp (overseas applicants)
Completed Equal Opportunities form
Relevant certificate of training
Proof of National Insurance Number
Copy of Driving License (if applying as a driver)
Copy of Insurance Certificate

Care Direct & Support Solutions Ltd | R/O 18 Bloomfield Avenue, Luton, Bedfordshire, LU2 0PS | Email: [email protected] |
www.caredirectandsupportsolutionsltd.co.uk | Tel: 01582 725 998/079 326 59527/078 603 805 94 | CQC Regulated|Company reg: 09892365