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GEOCARE APPLICATION FORM

Section 1: Personal Details

TitleTitle

First NameFirst Name

SurnameSurname

AddressAddress

Address 2Address

Postal CodePostal Code

Forenames (in full)Forenames (in full)

Previous Surname(s) (if any)Previous Surname(s) (if any)

Position Applied ForPosition Applied For

Fileupload

Upload Official ID

Emaila valid email

Home Tel :Phone Home

Mobile NoPhone Mobile

Date Moved to Current AddressDate Moved to Current Address

National Insurance NumberNational Insurance Number

Do you hold a current UK driving license?

YesNo

Do you own a car?

YesNo

Section 2: Education and Training

Please list your educational qualifications and training in chronological order with the most recent first. Feel free to continue on a separate sheet if necessary but Please ensure you attach any additional sheets securely.

School or OrganisationSchool or Organisation

0 /

From Dateof appointment

To Dateof appointment

Qualification or TrainingQualification or Training

0 /

Grade or Passmore details

0 /

School or OrganisationSchool or Organisation

0 /

From Dateof appointment

To Dateof appointment

Qualification or TrainingQualification or Training

0 /

Grade or PassGrade or Pass

0 /

School or OrganisationSchool or Organisation

0 /

From Dateof appointment

To Dateof appointment

Qualification or TrainingQualification or Training

0 /

Grade or PassGrade or Pass

0 /

Section 3: Employment History

Please list below a complete record of other employments and include, if you wish, any voluntary activities either paid or unpaid. These should be in date order, starting with the most recent. Please explain any gaps in employment.

Name of Organisation, nature of business and addressName of Organisation, nature of business and address

0 /

From Dateof appointment

To Dateof appointment

Job title and brief summary of duties and responsibilitiesmore details

0 /

Reason for leavingmore details

0 /

Name of Organisation, nature of business and addressmore details

0 /

From Dateof appointment

To Dateof appointment

Job title and brief summary of duties and responsibilitiesmore details

0 /

Reason for leavingmore details

0 /

Name of Organisation, nature of business and addressmore details

0 /

From Dateof appointment

To Dateof appointment

Job title and brief summary of duties and responsibilitiesmore details

0 /

Reason for leavingmore details

0 /

(Continue on separate sheet if required)

How many sick days have you had in the last 3 years?your full name

Please list the reasons for such sick days.more details

0 /

Do you have any commitments that prevent you from working certain hours/days? if so, please state below:

Reasons for not wanting to work certain hours.more details

0 /

Are you currently working?

YesNo

If so, how much notice must you provide to your current employer?more details

0 /

Section 4: Why would you like to work at GeoCare?

Please write a brief paragraph about why you want to work for GeoCare Services, why you want to work within the care industry and the qualities that you have that would make you the ideal candidate.

Why you want to work for GeoCare Servicesmore details

0 /

(Continue on a separate sheet if necessary)

Section 5: Further Information

Criminal convictions

As defined by the Rehabilitation of Offenders Act 1974 and subsequent regulations, under section 4.2 you do not need to declare convictions which are 'spent'.

However, by virtue of the Rehabilitation of Offenders (Exceptions/Amendments) Order 1986 those provisions do not apply if you are applying for a job supervising, caring for or otherwise connected with people from the following list, you must always declare any convictions and/or cautions for criminal offences, even where they are'spent'. For these purposes, this includes working with children, young and older people, those who are dependent on alcohol or drugs, and those with mental or physical disabilities, illness,injury or deformity, including people who are blind, deaf or without speech.

*Criminal conviction (Please state NONE if appropriate)

0 /

* Please note if you have any cautions orconvictions that you do not declare on this form then we will not be able tooffer you a position. Please list all cautions and convictions

References

PLEASE PROVIDE TWO PROFESSIONAL REFERENCES, ONE MUST BE YOUR CURRENT/LAST EMPLOYER

Referee 1

First Nameyour full name

Last Nameyour full name

Company Nameyour full name

Addressyour full name

Phone Work

Phone Mobileyour full name

Emaila valid email

Referee 2

First Nameyour full name

Last Nameyour full name

Company Nameyour full name

Addressyour full name

Phone Workyour full name

Phone Mobileyour full name

Emaila valid email

Declaration

The information that I have provided is to the best of my knowledge. I understand that giving false information or omitting relevant information could disqualify my application and, if I am appointed,could lead to my dismissal.

Signedyour full name

Dateof appointment

GeoCare Care Equal Opportunity Policy

We regularly review and improve our recruitment process; therefore we ask that you complete the following form to assist us with such improvements.

Information you provide in this form will not be used in selecting or not selecting you for an employment position, and is used to monitor our equal opportunities policy. This information is confidential and you will not be identified by any information you provide in this form. Completed forms will be detached from your application upon receipt and will not be held in employment files. This form is not part of your application.

Job Title Applied for:

Surnameyour full name

Genderyour full name

Forename(s)your full name

Marital Statusyour full name

Ethnic Origin (The following categories are recommended by the Commission for Racial Equality. If you feel the choices do not provide a suitable option, please write down how you would describe your ethnic origin)

A White

D Black or Black British

1 White British

11 Caribbean

2 White Irish

12 African

3 White other (please specify)your full name

13 Any other black background (please specify)your full name

B Mixed

E Chinese or other ethnic group

4 White and black Caribbean

14 Chinese

5 White and black African

15 Any other (please specify)your full name

6 Any other mixed background (please specify)your full name

C Asian or Asian British

7 Indian

8 Pakistani

9 Bangladeshi

10 Any other (please specify)your full name

Next of Kin and Doctors

Emergency Contact Details

Can you please fill in this section so we have apoint of contact for you as an emergency contact number.

Your Nameyour full name

Next of Kin Nameyour full name

Relationshipyour full name

Phoneyour full name

Addressyour full name

Next of Kin Nameyour full name

Relationshipyour full name

Phoneyour full name

Addressyour full name

Next of Kin Nameyour full name

Relationshipyour full name

Phoneyour full name

Addressyour full name

Doctor Details (if any)

Nameyour full name

Surgeryyour full name

Contact Numberyour full name

If these details change, can you please ensure the office is made aware. These contacts will only be used in an emergency.

Holidays Booked

Full Nameyour full name

Date Completedof appointment

Do you have any holidays booked within the next year?

YesNo

If so, please specify datesmore details

0 /

Notice:

GeoCare Services requires certain information prior to candidates commencing employment, to ensure performance requirements for the position are met and a reliable service is provided. This information is to ensure compliance with relevant Health and Safety regulations. The information is also required in order to establish whether any reasonable adjustments may need to be made to assist you in performing your duties, in accordance with the Disability Discrimination Act 1995. All information provided is kept confidential and used only for the purposes detailed above in compliance with the Data Protection Act 1998.

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