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Application form

Position applied for *

Date available to take up employment *

Salary expectations *

Prepared for work

Full timeYesNo

Part timeYesNo

Shift workYesNo

Personal details

Full Name

Title *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Home Number

Mobile Number

Email Address

National insurance number

Passport number

Do you own a car?YesNo

Issue Date

Have a current licence?YesNo

If yes, licence typeProvisionalFull

Driving licence number

Do you have any current driving convictionsYesNo

If yes, give details including dates

Further education and training

University/College and date attended

Type of course

Subjects

Qualification or class of degree

Occupational qualifications

College/Institute or other name and date attended

Qualification/Level

Membership of professional body

Name

Level

Date

Previous employment

A full work history is required explaining any gaps in employment.

Present/last employer

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Job title

Duties/responsibilities

Start date

End date

Reason for leaving

Employers name & address

Job title

From

To

Reason for leaving

General

Interests/hobbies (give details of pastimes, sports, etc)

Offices held in social/sports clubs, etc

Public duties ( local councillor, etc) undertaken

If offered this position will you continue to work in any other capacity?YesNo

If yes, give details

Permission 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?YesNo

If you are successful in your application would you require permission to work in the UK?YesNo

Community/volunteer experience

Name and address of organisation

Position/title

Duties

Statement in Support of Application- please tell us your personal qualities, skills and attributes, experience and any achievements or information to show how you meet criteria needed for this job

Next of kin

Emergency contact name

Relationship to you

Contact number

Referees

Work reference

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Organisation

Occupation

Telephone number

Email Address

The Data Protection Act 1998 requires that any staff handling personal data must follow certain principles in relation to the data that they hold. Individuals have rights of access to data that is held and rights to claim for damages if various offences occur. This covers manual as well as computerised records.

In implementing the legislation, TLC Healthcare adopts a simple and straightforward policy.

If you are unsuccessful in this application, we will keep this form on file for 6 months should you wish to be considered for other vacancies within TLC Healthcare.

Please tick to show your agreement to this.

I Agree

Date of previous application

Previous position applied for

Did the application go through to interviewYesNo

Criminal Record Check I have completed / will complete an application for a criminal record check and can further state that to the best of my knowledge and belief, there will not be any positive disclosure made that will preclude me from working with vulnerable adults or children.

I also give permission for a copy of the disclosure to which I am subject, being made available to a named authorised person upon written request, who acts on behalf of a National Government or Local Government Department for auditing purposes.

Name

Date

Working with TLC Healthcare

It is TLC Healthcare’s policy to employ the best qualified personnel and provide equal opportunity for the advancement of employees including promotion and training and not to discriminate against any person because of race, colour, ethnic origin, national origin, sex, sexual orientation, religion or belief, pregnancy, trans-gender status, marital or civil partnership status, age or disability.

I authorise TLC Healthcare to obtain references to support this application once an offer has been made and accepted and release TLC Healthcare and referees from any liability caused by giving and receiving information.

DECLARATION

I confirm that the information given on this form is, to the best of my knowledge, true and complete. Any false statement will be sufficient cause for rejection or, if employed, dismissal.

I Agree

Name

Date

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