APPLICATION FORM

Application for the post of:…………………………………..

A. PERSONAL DETAILS (please complete in BLOCK CAPITALS)

Surname:..........................................................................................................................

Forename(s):……………………………………………………………………………………

Address:………………………………………………………………………………………..

…………………………………………………………………………………………………..

……………………………. Post Code:……………………………………………………..

Telephone: ……………………………………………………………………………………

Date of birth:.................................................................................................................

N.I Number……………………………………………………………………………………
:

B. ADDITIONAL PERSONAL DETAILS (please complete in BLOCK CAPITALS)

Nationality……………………………………………………………………………..:…….

Religion………………………………………………………………………………….:……
Are you registered disabled? YES NO

RDP Number:………………………………………………………………………………. ..

Are you in good health? YES NO

Are you aware of any medical or physical factors which might affect your performance of the job
for which you are applying
E.g. weak back/lifting)?

If ‘yes’, please give details below: YES NO

...................................................................................................................................

………………………………………………………………………………………………..

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Available to take up employment with effect from (date):……/……../…………………..

Prepared to work (please tick) FULL PART -TIME

C. PREVIOUS ADDRESS (Provide your most recent address where you have lived in
the last 5 years, use additional sheet if necessary )

Address:…………………………………………………………………………………………

Town/City:……………………………………………………………………………………….

County:…………………………………………………………………………………………..

Post Code:………………………. Country:……………………………………………………

Period at previous address: From date:……/………/……… To date:…./……/…………

Address:…………………………………………………………………………………………..

Town/City:…………………………………………………………………………………………

County:…………………………………………………………………………………………….

Post Code:………………………… Country:…………………………………………………..

Period at previous address: From date:……/……/………. To date:……../……./…………

D. ADDITION INFORMATION (please tick)

Current marital status: Single Married Divorced Widowed Separated

Other:……………………..

Number of children under 18:………………………

Employment status: Employed Self-Employed Part-time Employed

Unemployed Student Other…………………………….

Do you currently have a full UK Driving Licence? YES NO

Do you own a car? YES NO

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Are you eligible to work in the UK? YES NO

(if you are not a UK resident, you will need to provide proof)

E. EDUCATION / QUALIFICATION
SCHOOL/COLLEGES DATE DATE DETAILS OF QUALIFICATION DATE
FROM TO

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 F. TRAINING (please give details of all training and other courses, which you have
Undertaken, particularly those relating to care)

YEAR COURSE TITLE ORGANISING LENGTH OF COURSE

BODY

G. EMPLOYMENT HISTORY (please provide details of all employment beginning.

with your present or most recent job)

DATES EMPLOYER SALARY POSITION(S) REASON FOR LEAVING

HELD
FROM TO

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 H. NEXT OF KIN

Title: Mr Mrs Miss Ms Other………………………..

Surname:…………………………………………………………………………………

Forename(s):…………………………………………………………………………….

Contact Number(s):……………………………………………………………………..

Relationship:……………………………………………………………………………..

CRIMINAL RECORDS BUREAU

Excellence Healthcare is registered with the Criminal Records Bureau (CRB) Disclosure
service. This service is used to assess the suitability of applicants for positions of trust, it
is the policy of Excellence Healthcare that all appointments are subject to verification from
the CRB Disclosure service and it undertakes not to discriminate unfairly against any
subject of a Disclosure on the basis of conviction or other information revealed. In
accordance with the Rehabilitation of offenders Act 1974 we require all applicants to
disclose any unspent criminal convictions.

Have you ever been convicted of any criminal offence other than a spent conviction under

Rehabilitation of offenders Act 1974? (Please tick as appropriate) YES NO

IF YES please give details below: ……………………………………………………..

……………………………………………………………………………………………..

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 REFERENCES please provide details of two people (Not friends or relatives) who
Contacted for references in connection with the application.

Name:................................................................ Name:...............................................................

Company Name:…………………………………. Company Name:…………………………………

…………………………………………………….. ……………………………………………………..

Job Title:…………………………………………… Job Title:………………………………………….

Address:……………………………………………. Address:…………………………………………..

……………………………………………………… …………………………………………………….

……………………………………………………… …………………………………………………….

………………..Post code……………………….. ………………Post code………………….........

Tel:..................................................................... Tel:...............................................................

Fax:………………………………………………… Fax:…………………………………………….

Capacity in which known to…………………….. Capacity in which known to………………….

…………………………………………………….. ………………………………………………….

Can we contact the above prior to interview? Can we contact the above prior to interview?

YES NO YES NO

DECLARATION:
I declare that all statement given in this form are true and correct to the best of my knowledge.
I understand that should I make any false statement or knowingly give incorrect information
or conceal any fact relevant to this application I will, if appointed, be liable to dismissal.
Signed…………………………………………. Date:…………………………………..

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 EQUAL OPPORTUNITIES MONITORING
In other to assist us in monitoring the effectiveness of our equal opportunities policies and
procedures you are requested to give the following information.

Applicant………………………………. Age………………… Male Female

ETHNIC ORIGIN

I would describe my ethnic origin as:

Indian Black – African

Pakistani Black - Caribbean
Bangladeshi Black – other………………..
White – united kingdom Chinese
Irish Vietnamese
White – other……… other……………..

Birthplace Town and country…………………………………………………………………………..

Language used………………………………………… Religion (if any)……………………………

CONFIRMATION

I confirm that above information is correct,

Signature……………………………………
Date…………………………………………………………

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