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1 Metro House Office 6, 57 Pepper Road, Leeds, LS10 2RU Tel: / Mob: APPLICATION FORM IN CONFIDENCE We are an equal opportunities employer. Please note that because we are caring for vulnerable adults, all employees are subjected to a Criminal Records Bureau check. At interview you will be asked to bring your passport, birth and civil partnership or marriage certificates, as proof of your identity, and documents to prove you address such as a photo driving license, utility bills, mortgage statement/ rent agreement, credit card statements and letters from public bodies. For nurses only NMC PIN number for limited company: registration number. Post applied for:. Date of application: Personal Details Mr/Mrs/Miss/Ms First Name(s): Surname: Address: Postcode: How long have you lived at this address?... Home Tel No: Mobile No: NURSES ONLY PIN NUMBER: Please circle as appropriate PAYE/LIMITED COMPANY LIMITED Company registration number: address: (please print clearly) How did you hear about this company? Jobcentre Reed Word of mouth Social Media Website Other. Do you have a full membership with the RCN? Do you have Professional Indemnity Insurance? PERSONAL INFORMATION (please circle where required) National Insurance Number Bank/ B.S Name: Nationality: Acct Name: Do you have a current Passport? Please circle: Male/Female Sort Code: Do you have a current UK Date of Birth: Acct No: 1 driving license? Do you drive?

2 Previous surnames and dates of use: 1. From.. to.. 2. From.. to.. Previous forenames and dates of use: 1. From.. to.. 2. From.. to.. Martial or civil partnership status (optional):... Date of marriage/civil partnership (optional):.. Next of Kin details:.. Relationship:.. Education and training Please provide a record of your education and training starting with the earliest. School/College or training course Qualification or achievement Dates (optional) Please continue overleaf if necessary 2

3 Work History Please provide details of your employment record beginning with the earliest. Employer s details Nature of work/job title Reason for leaving Dates (optional) Please continue overleaf if necessary a) if there are any gaps in your work history, what were you doing at that time? b) have you ever been subjected to disciplinary procedures in any of your previous job? If so, why?... Have you ever been suspended from work? If so, why?... Have you ever had your employment terminated by an employer? If so, why? 3

4 References EyesOnCare Recruitment LTD Before an appointment can be made, a minimum of two satisfactory references will be needed. Please provide details of two referees, one of whom should be your current or last employer. If you have ever worked one referee should be somebody who knows you professionally such as a teacher. The other referee should not be related to you either directly or by marriage or character reference. Name and address and of referee 1. Their telephone number Length of time they have known you Nature of relationship (e.g. employer/friend) 2. Absences 1. How many days have you been absent from work in the last 12 months a. Unauthorised leave?...days b. Authorised leave?...days Privacy Notice We process personal data relating to those who apply for job vacancies with us who send speculative job application to us. We do this from employment purposes, to assist us in the selection of candidates for employment, and to assist in the running of the business. The personal data may include identifiers such as name, date of birth, personal characteristics such as gender, qualifications and previous employment history. We will not share any identifiable information about you with third parties without your consent unless the law allows or requires us to do so. The personal data provided during an application process will be retained for a period of at least six months or, if required by the law, for as long as required. This privacy notice does not form part of an employment offer or contract between us. If we make an employment offer to you, we will provide further information about our handling of our personal information in an employment context separately. If you would like to find out more about our data retention policy and how we use your personal data, you want to see a copy of the information about you that we hold or have any 4

5 questions or issues regarding data protection, please us with the subject Data Protection Request. Declaration under the Protection of Freedoms Act 2012 The post for which you are applying is a regulated activity within the meaning of Part 5, Chapter 1 of the Protection of Freedoms Act 2012 and it is a CRIMINAL OFFENCE for a barred person to apply to work in a regulated activity. If you are a barred person you MUST NOT procced with this job application. If your application is successful you will be required to co-operate with us in obtaining a disclosure of criminal convictions and in checking your barred status with the Disclosure and Barring service Rehabilitation of Offenders Act 1974 (ROA 1974) The post you have applied for is exempted from this Act by the Exceptions Order Because the duties involve caring for vulnerable adults you are required to disclose details of any criminal record. Only relevant convictions and information will be taken into account. Disclosure, is not, therefore, necessarily a bar to employment. Any information provided will be kept in confidence. Have you ever been convicted by a court or cautioned, reprimanded or given a warning by the police? If yes, please provide details and dates of the offences and penalties Are you aware of any police enquiries current or otherwise which may have a bearing on your suitability for this job? If yes please provide details.. Declaration I confirm that the information provided in this form is accurate and understand that misleading or inaccurate statements may lead to the cancellation of any subsequent employment offer, or the termination of any resultant employment. I understand that a Criminal Record Bureau disclosure will be sought in the event of a successful application. The required fee for the CRB application will be deducted from my first wage as well as the cost for the uniform tunic an name badge. Signed: 5

6 Dated:. Please provide details below of any special requirements you may have for attending an interview: Official use only Conditional offer Date: Disclosure request Sent Returned Reference 1 Sent Returned Reference 2 Sent Returned Job offer Sent Returned Offer confirmed If no, reason discussed If yes, trial shift date Employment from Date: Date: 6

7 If you are a successful candidate, you will be invited to interview, where you will need to provide the following documentation. Please keep a note of this page for your records. Required documentation: - Photo ID (Valid Passport, driving Licence) - Full Birth Certificate - 2 letters with Proof of Address dated within the last 3 months (utility bill, bank statement, letter from DWP/council or home office) - Proof of National Insurance Number (P45/P60/ National Insurance card/ Government notification of NINO) - Mandatory training Certificates (i.e. First Aid manual, Food Hygiene etc.) - 2 references (one must be from your last or current employer to include telephone number and address) - Copy of Your CV or you must have the ability to recall the last 10 years of your employment history - Right to work documents f required (residency permit, leave to remain, work visa) - Copy of your DBS - DBS Update service number if registered online If you have completed your mandatory training within the last 12 months you will need to provide your certificates, so we can copy them and hold them on file. If you need to do your mandatory training, you will be expected to do this as part of the interview process so please book out for your interview a fill morning or afternoon. If you have any questions, please do not hesitate to contact me on / or I look forward to meeting you. Our address is: Unit 6 Metro House 57 Pepper Road Leeds, LS10 2RU 7