Application Form – Fembistem

Fembistem Care

Halton Mill, Mill Lane, Halton, Lancaster, LA2 6ND

Please ensure that you complete the application form in full. This form will be kept in confidence. Please note that no applicant will be unfairly discriminated against. This includes discrimination on account of age, cultural, religious, political beliefs, disability, ethnicity, gender, race, relationship status, sexual orientation ,and/or Trade Union membership or stewardship.

If you have any special requirements to support you to complete this form(e.g. the need for large print or additional time), please contact the Registered Manager.

Position Applied For:

Location *

Work Preference:

Full TimePart TimeBank

Hours Requested:

I understand this role may include: Shift work, Unsociable Hours, Lone working involved. (Please circle your availability below) *

YesNo

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Personal Details

Prefix

First Name

Middle Name

Last Name

Address:

Surname:

Postcode:

Maiden Name:

Nationality:

Previous Names:

NI Number:

Marital Status:

Email Address *

Gender:

Own Transport

YesNoN/A

Date of Birth:

Any Endorsements:

YesNoN/A

Place of Birth:

Telephone Number:

Mobile Number:

Are you a Driver:

YesNo

How long have you had a licence?

Are you a UnitedKingdom(UK), European Community(EC),European Economic Area(EEA) National

YesNo

Including Visa number

Are you related to any of our current members of staff or Service Users?

YesNo

Equality Act 2010 - Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a “substantial” and“ long-term adverse effect ”on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at :www.gov.uk/definition-of-disability-under-equality-act-2010.

For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?

Education *(All qualifications will be subject to a satisfactory check).

School / University

Date From

Date To

Examinations *

Training Courses attended or completing (evidence of attending courses is required)

Subject

Location

Date

Details

Professional Memberships / Registrations

Name of Organisation

Registration Number

Renewal Date

Details

Employment History

Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained. Use a separate attached sheet if required; please sign the sheet(s)

Current / Most recent employer

Start Date:

End Date:

Salary:

Job Role:

Employer Name:

Reason for Leaving:

Contact Name:

Duties:

Address:

Postcode:

Telephone Number:

Email:

Employment History

Start Date:

End Date:

Salary:

Job Role:

Employer Name:

Reason for Leaving:

Contact Name:

Duties:

Address:

Postcode:

Telephone Number:

Email:

Name:

Position:

Company:

Address:

Email Address:

Description (who is this reference to you?):

Please provide at least two references from your past employments.

Reference - 1

Name:

Position:

Company:

Address:

Email Address:

Description (who is this reference to you?):

Reference - 2

Name

Position:

Company

Address

Email Address:

Description (who is this reference to you?):

Safeguarding/Ex-Offernders Declaration: Please not this section will only be seen by those involved in the recruitment process and will be treated with the strictest confidence.

The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. Genius Care Limited undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.

Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

Are you currently bound over or do you have any current UNSPENT convictions tha thavebeen issued by a CourtorCourt-Martialinthe United Kingdom or inanyother country?

YesNo

Do you have any current UNSPENT police cautions,reprimands or final warnings in the United Kingdom or in any othercountry?

YesNo

We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to holding the information contained with in this application form. If successfully shortlisted, da ta will also include short listing scoring and interview records. We would like to keep this data until the vacancy is filled. (We can not estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you).When that period is over, we will either delete your data or in form you that we would like to keep it in our database for future roles.

We have privacy policies .Please be assured that your data will be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant post.

You have the right for your data to be deleted, corrected, or accessed, to restrict processing, to revoke consent, and to be kept informed about the processing of your data. If you would like to talk about this more or revoke your consent at any time, please get in touch with the registered manager to discuss.

Declaration

The information in this application formistrueand complete. I accept that any will ful omission, fabrication, or misre presentation in the application form will result in the rejection of this application or, if employed, the subsequent termination. Where applicable, Icon sentthatcan seek clarificationregar ding professional registrationdetails.

Print Full Name:

Date:

CV:

No file chosen

Supporting Statement

Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be beneficial to list specific abilities and talents that set you apart from others, as well as knowledge acquired via employment, school, and extracurricular activities.