Join Us – Shalom

Registration Form

Post applying for?

Full Name

Phone Number

Address

City

Country

Postal Code

Country

National Insurance Details:

Do you have the right to work in The UK?

Yes No

Please provide details of your visa and any restrictions in the space provided below (if applicable)

Do you drive a car?

Yes No

Are you happy to drive to work?

Yes No

Next of Kin.( For emergency contact)

Relationship

Next of Kin Address

Next of Kin Email

Next of Kin Mobile

Full Employment History

References

Contact Name

Job Title

Address

Tel

Relationship to you

Number of years known

EQUAL OPPORTUNITY MONITORING FORM

OTHER ETHNICITY (Please state)

GENDER

Male Female Other

DO YOU CONSIDER YOURSELF TO HAVE A DISABILITY OF SOME KIND?

Yes No

If yes, give details

Disclosure of criminal record information

HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE, OR BEEN SUBJECT TO ANY CONFIDENTIAL DISCHARGE, BIND-OVERS OR CAUTIONS?

Yes No

If yes, give details

HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENCE?

Yes No

If yes to question above, please give details.

HAVE YOU EVER RECEIVED ANY OFFICIAL CAUTIONS, REPRIMANDS OR WARNINGS?

Yes No

If yes to question above, please give details.

ARE YOU CURRENTLY THE SUBJECT OF ANY CRIMINAL PROCEEDINGS OR ANY POLICE INVESTIGATION?

Yes No

If yes to the question above, please give details.

I declare that I do not possess, nor have I ever possessed a criminal conviction, nor have I been subject to any conditional discharges, bind-overs or cautions

ANY INFORMATION CONTAINED IN THIS FORM WILL BE TREATED IN CONFIDENCE. FAILURE TO DISCLOSE ANY RELEVANT INFORMATION OR PROVIDING FALSE OR INACCURATE INFORMATION MAY BE REGARDED AS A BREACH OF ANY SUBSEQUENT CONTRACT OF EMPLOYMENT, RESULTING IN DISCIPLINARY ACTION AND / OR DISMISSAL.

HEALTH CHECK QUESTIONNAIRE GP Contact Details

PLEASE ANSWER THE FOLLOWING QUESTIONS BY GIVING RELEVANT DETAILS

Have you ever suffered from any of the following:

DEPRESSION, ANXIETY STATE, NERVOUS ILLNESS OR BREAKDOWN

Yes No

If Yes

EPILEPSY OR DISEASE OF THE NERVOUS SYSTEM

Yes No

If Yes

AILMENT OF LUNGS OR CHEST

Yes No

If Yes

SPINAL PROBLEM (BACKACHE)

Yes No

If Yes

ARTHRITIS, RHEUMATISM OR GOUT ETC

Yes No

If Yes

ANY HEART OR CIRCULATORY, INCLUDING BLOOD PROBLEMS

Yes No

If Yes

ILLNESS OF THE KIDNEYS, BLADDER, LIVER OR GLANDS

Yes No

If Yes

DIABETES

Yes No

If Yes

SKIN DISORDER

Yes No

If Yes

Are you presently taking medication or undergoing treatment. If so give details.

ARE YOU A REGISTERED DISABLED PERSON?

Yes No

How many working days have you been absent from working during the last 12 months (apart from holidays)

Additional Details: (if necessary)

Notes

Data Protection:

THE HEALTHCARE RECRUITMENT PRIVACY STATEMENT IS AVAILABLE ON OUR WEBSITE (WWW.DWCSLTD.CO.UK) OR A COPY CAN BE REQUESTED FROM THE HUMAN RESOURCES DEPARTMENT. PLEASE SIGN BELOW TO CONFIRM YOU HAVE ACCESSED THE DRITEWISE CARE AND SUPPORT LIMITED HEALTHCARE RECRUITMENT PRIVACY STATEMENT AND YOU HAVE READ, UNDERSTOOD AND AGREE TO ALL THE TERMS STATED.

Data

Name

DECLARATION

I DECLARE THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TO THE BEST OF MY KNOWLEDGE, COMPLETE AND CORRECT. I ACCEPT THAT SHOULD ANY STATEMENT MADE BY ME IN CONNECTION WITH THIS APPLICATION BE FOUND TO BE FALSE, INCOMPLETE OR MISLEADING THEN THE APPLICATION SHALL BE VOID AND CONSEQUENTLY, DRITEWISE CARE AND SUPPORT LIMITED MAY TERMINATE ANY CONTRACT ARISING AT ANY TIME. BECAUSE OF THE SENSITIVE NATURE OF THE DUTIES THE POSTHOLDER WILL BE EXPECTED TO UNDERTAKE, I UNDERSTAND THAT THE DECLARATION WILL INCLUDE DETAILS OF ANY CRIMINAL CONVICTIONS, CAUTIONS, REPRIMANDS AND FINAL WARNINGS THAT ARE NOT ‘PROTECTED’ AS DEFINED BY THE REHABILITATION OF OFFENDERS ACT 1974 (EXCEPTIONS) ORDER 1975 (2013) AND ANY OTHER INFORMATION THAT MAY HAVE A BEARING ON MY SUITABILITY FOR THE POST. I ALSO UNDERSTAND THAT THE RELEVANT LEVEL OF DBS CHECK WILL BE SOUGHT IN THE EVENT OF A SUCCESSFUL APPLICATION

Name

Date

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ShalomCare & Home Ltd