Application Form Application Form Name * First Surname * Last Name of Position * The job title you would like to apply for. National Insurance Number * Address Line 1 Address Line 2 Town County Postcode Telephone Number Mobile Number Email Address Are you a Welsh speaker? (please describe level of fluency) e.g. No, A little Welsh, Verbal Understanding, Written Understanding, Fluent etc. Current Employer Please provide full details of your current employment. Position Employer Address Salary Start Date Reason for Leaving Previous Employer 1 Please provide full details of your previous employment. Position Employer Address Salary Start Date End Date Reason for Leaving Previous Employer 2 Please provide full details of your previous employment. Position Employer Address Salary Start Date End Date Reason for Leaving Gaps in Employment Please list and account for any gaps in employment. Please provide dates and details for any gaps in employment. Activities & Interests What clubs, societies, organisations do you belong to? Any positions of responsibility? If you had more time / money, what hobbies would you like to take up? Education & Training Schools attended from age 11 Examination results Further education colleges Qualifications, including vocational training Are you registered with the Care Council for Wales? Please provide your registration number. Health & Fitness for Work Please provide details of any disability or injury, which may affect your ability to work. Please give details of any injury you have suffered whilst at work. Are you receiving physiotherapy or similar treatments? Are you being prescribed any form of medicine or drugs? Have you had any time off for stress or stress related illnesses in the past 10 years? Please provide details. How many absence days off have you had in the past 12 months? Do you smoke? Yes No Are you registered disabled? Yes No Are you colour blind? Yes No For CRB checks, we require your addresses for the last 5 years Address Postcode Date From Date To Add Remove Other Matters Do you have a current full driving licence for manual cars? What date did you pass your driving test? What is your notice period? Do you have any holiday commitments? Are there any other key factors that may affect your regular attendance at work? Offending History (You do not have to declare any spent convictions as defined under the Rehabilitation of Offenders Act 1970). Please note that any offer of employment will be subject to a full disclosure via the Criminal Records Bureau. Have you ever been convicted of a criminal offence, had a caution, reprimand, or a police investigation that may raise questions as to your suitability? Please provide details. References - Current Employer Please provide details of a person we can contact for a reference. This first reference must be from your current employer. (N.B. references will not be taken until you are offered a position and agree for us to contact them) Name Address Telephone Number Email Address References - Personal Reference Please provide details of a person we can contact for a reference. (N.B. references will not be taken until you are offered a position and agree for us to contact them) Name Address Telephone Number Email Address Have you worked at any care homes before? Please list below any Care Homes that you have worked in with their contact details. We reserve the right to take up references from any or all of these homes. Name of Care Home Address Telephone Number Add Remove Further Information Please use this space to add any further information you think relevant to support your application including why you believe you have something to offer this organisation. Further information I would like to add. Declaration The information on this form is true. I understand that if I am offered a job and I have given false or misleading information this would lead to a withdrawal of the offer, or dismissal without notice if I have already commenced work. I also understand that any offer and the resulting employment will be conditional on satisfactory references, Disclosure Barring Service checks and registration by the Care Council for Wales. Signed by Date Health Screening Check Name Date of Birth Sex Name of G.P. Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Next of Kin Relationship Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Phone Number Details of previous serious illnesses, injuries & allergies Details of any regular prescriptions Phone Number Inoculations It is strongly recommended that all inoculations are up to date to protect you from any unnecessary risk. Tetanus Hepatitis B Tuberculosis Rubella Mumps Whooping Cough Diptheria Polio Measles Signature I agree the above statement is a true and accurate record. Please note any falsification may affect your employment rights. Signed by Date Email Address Landsker Childcare will use your data to process your job application. We will not share your information with anyone else but we may keep your application for future reference. You are entitled to request a copy of this data and ask that it be deleted at any point. Please read our privacy policy for more details. * I understand and agree to the use of my data.
