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Apex House, Carthobe Rd B15 1TR
0121-369-0161
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Full Application
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Thank you for your interest in applying for a position with Lady Byron. To process your application quickly and smoothly we require all potential applicants to complete and submit the following application form (pages 1 to 7). You will also be able to upload your CV (see page 3). Note Minimum Age: Legislation dictates that Care Workers must be 18 years old or older, and Carers working with people with learning disabilities must be 21 or older. If you do not meet these specifications get in touch with us before filling in the application form.
Title
Mr
Mrs
MIss
Transgender
Doctor
First Name
Last Name
Telephone Number
Email
Address
Postcode
Approximate number of working hours wanted
NHS Number
Do you have a valid driving licence?
Yes
No
Are you double vaccinated?
Yes
No
Do you have your own transport?
Yes
No
Position Applied
Support Worker
Live-in Career
Overnight Career
Children Worker
Select one
Our Values
We are a family run home care business that is committed to providing people with friendly, reliable, trustworthy and competent Carers who take great pride in being and doing the very best they can. We would like you to demonstrate how you share our four core values.
As a Carer why do you think it's important to be friendly, reliable, trustworthy and competent?
DBS Certificate
The following information is required for DBS check purposes. Please complete where applicable.
Do you have a DBS Certificate?
Yes
No
If YES please insert DBS Certificate Number:
Have you registered your DBS on the update system?
Yes
No
If YES please provide the ID Number:
If YES please provide the ID Number:
Date of change of last name
Any other last names
Date of change of last name
Previous Addresses
Please provide your previous addresses for the last 5 years below. this information is required for DBS Check purposes
10/2023 to 11/2024 51 London way, Birmingham, b1 1ts
Education, Training and Employment History
You can upload your CV instead of completing the information below on your Education, Training and Employment History
Upload CV
Personal Statement why you feel thiis role is suits you and
Education
School/College/University 1
Name of School/college/ University - start year - End Year - Qualification
Training
Training/Short Courses
Name of Course - Date of Completion
Referees
You must provide references from your two most recent employers. Please provide an additional character referee. All referees will be contacted, therefore please inform them that you have provided their details. If you are unable to give the required references, please discuss the matter with us.
Current Most Recent Employer
Name
Position
Company
Telephone Number
Email
Previous employer to the above
Name
Position
Company
Telephone Number
Email
Character Reference
Name
Position
Company
Telephone Number
Email
Next of Kin
Name
Last Name
Relationship to youd
Telephone Number
Email
Address
Postcode
Bank Details (where you would like to be paid into)
Name Of Bank
Name of Account Holder
Sortcode
Account Number
National Insurance
National Insurance Number
NHS Number
NHS Number
Capacity to work in the UK
Are there any restrictions to your residence in the UK that might affect your right to take up employment in the UK?
Yes
No
If YES please provide details
If YES please provide details
If you are successful with your application, would you require a work permit prior to taking up employment?
Yes
No
Equal Opportunities Monitoring Form
Home Counties Carers is committed to promoting equal opportunities for all its employees and all prospective employees.
To ensure that all applicants are dealt with equally, we wish to monitor your recruitment process and would ask for your help by completing the details below. This will allow Home Counties Carers to monitor its policies.
Please note you do not have to complete this form. The information is given on a voluntary basis and the information provided will only be used for monitoring purpose and will remain confidential. This information will be stored on a computer.
1. Gender
Female
Male
Other
2. Are you registered as disabled?
Yes
No
3. Marital Status
Married
Single
Divorced
4. Do you have children
Yes
No
5. Please indicate your ethinc background
Arab
Asian or Asian British
Black or Black British: African
Black or Black British: Caribbean
Mixed: White and Asian
Mixed: White and Black
Mixed: Other
White British
White Irish
White Other
Other ethnic group
6. Age
1
2
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Declarations
IMPORTANT – READ BEFORE SIGNING
Disclosure and Barring Service
Employees of Lady Byron Carers are subject to the Health and Social Care Act 2008, and will be subject to a Police record check through the DBS. Our policy for the secure handling of information provided by DBS can be provided on request..
If you have any please declare below all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.
Charges and convictions
You will not be eligible for work in a care setting if you are listed on the DBS Adults Register.
A criminal conviction or caution will not necessarily exclude you from working with Home Counties Carers. All applications are considered in the same way. Suitability is assessed against our 4 core values. The hiring manager is responsible for assessing the risks disclosed in a DBS and at their discretion if an offer of employment is made.
I understand that I cannot be offered a post until a satisfactory response has been received with respect to my DBS status. Should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my current or most previous employer.
Working time and health disclaimer (optional)
1. I hereby agree to opt – out of the`48 hour working week limitation, as laid down in the Working Time Regulations 1998. I understand that I can end this agreement by giving one week’s notice in writing to Home Counties Carers.
Tick box to show agreement
2. I am in a good state of physical and mental health. I understand that it is my responsibility to inform Home Counties Carers immediately if there is a change in my medical condition that may affect my ability to do my work.
Tick box to show understanding
In submitting this form, I authorise the organisation to request an ISA Register check and a records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my ISA Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status. In submitting this form I declare that to the best of my knowledge and belief, the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.
Name
date
Send
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