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					                                 “ACME CARE LTD”
                                 Application for Employment
Data Protection Act 1998.                                              Once completed, please return to:
                                                                       Mrs E Price
The personal data you                                                  Acme Care Ltd
provide will be used for the                                           Second Floor
purpose of recruitment and                                             Cash’s Business Centre
selection only, enabling us to
                                                                       Cash’s Lane
protect the interest of the
employer and client.                                                   Coventry
                                                                       CV1 4PB




                                  Please Complete Using Black Ink


                                              Job Title:

                                       “Personal Assistant”

              Please underline the type of employment in which you are interested:

                 “Full Time”         “Bank”         “Part Time”          “Job Share”


        PERSONAL DETAILS (please complete using BLOCK CAPITALS)

        Salutation: Mr / Mrs / Miss / Ms      (delete as applicable)

        Surname ……………………………………………………

        Forenames…………………………………………………………………….………

        Address………………………………………………………………………...………

        …………………………………………………………...……..………………………

        Postcode……………………………………………………….………………………

        Telephone No………………………………………………………...……….………

        Mobile No………………………………………………………………..…………….

        Work No………………………………………………………………..………………


        National Insurance Number………./………./……..../……..../…..


                                                                                               Page 1 of 11
MULTIPLE EMPLOYMENT
(We need this information for Income Tax and National Insurance purposes).

        Please detail any current employment, the number of hours worked per week and whether or
        not you pay tax and insurance already. Also, do you intend to continue in this employment?




                 Please complete this section if it is relevant to the job you are applying for,
              Do you hold a full           Class of licence held?            Do you have the use of a
           current driving licence?                                                     car?
                  Yes / No                                                           Yes / No

PRESENT EMPLOYMENT
        Name of Employer:

        Address:

        Telephone No:

        Job Title:

        Date of Appointment:

        Period of notice required:

        Present Salary and any other benefits:

                     (Your present employer will NOT be contacted without your permission)

PREVIOUS POSITIONS
Either “paid” or “voluntary” work (most recent first please).

        Dates to
                            Employer              Position held    Salary       Reason for leaving
        and from




                                                                                                   Page 2 of 11
SECONDARY EDUCATION
Please include all secondary education and approx dates.

                School or secondary education and address                     Dates of attending




OTHER EDUCATION
Details of any qualifications and training.
Please include any overseas training that may be relevant to the post for which you are applying.

             Level                  Subject              Grade        Date        Where Awarded?




Include all qualifications e.g. GCSE, O Levels, A Levels, NVQ’s, Professional Examinations or higher
education.

RELEVANT TRAINING COURSES
Please list courses or training, which may be relevant to the post for which you are applying.

         Date from         To        No. of days       College or Organisation           Course title




                                                                                                    Page 3 of 11
PERSONAL STATEMENT
Please tell us how you feel you meet the requirements of the position for which you are applying.
Explain how / where you acquired these skills, knowledge or abilities - whether through work experience,
spare time activities, voluntary work etc. Please continue on a separate sheet if necessary.




                                                                                                 Page 4 of 11
REFERENCES
Please give the names of two people who can provide a reference to indicate your suitability for the post for
which you are applying.
The first referee, if possible, should be your present or most recent employer.

       Referee One                                      Referee Two


       Name:                                            Name:



       Address:                                         Address:




       Telephone no.                                    Telephone no.



             Do you know each of these people – “Professionally” or “Personally”?

          ……………………………………                                        ………………………………….

     Are you happy for us to take up the above references without first contacting you?

                                                  Yes / No

        Please indicate below, any dates when you will not be available for interview:

    …………………………………………………………………………………………………




Declaration

“I certify that, to the best of my knowledge, the information given on this form is current
and accurate.”

“I understand that my application may be rejected, or that I may be dismissed, if it is found
that I have withheld relevant information or supplied false information.”



Signature…………………………………………………………..Date……………



                                                                                                   Page 5 of 11
                         “ACME CARE LTD”
                                  Equal Opportunities
    Acme Care Ltd. is working towards equal opportunities in employment and service
          delivery. To help us to do this, please complete the section below.

Job Title………………………………………………………………………….……………………

Full Name……………………………………………………………………….…………………….

Gender:     Male / Female (delete as applicable)        Date of Birth……………….

Ethnic Origin: (please tick)

      Bangladeshi                                  Indian
      Black – African                              Irish
      Black – Caribbean                            Pakistani
      Black – other (please specify below)         White
      Chinese                                      Other (please specify below)

      ………………………………………………….……………………...……………..…..


How did you hear about the vacancy?……………………………………………………….

Do you consider yourself disabled? (delete as applicable)    Yes / No

Note for disabled candidates
We guarantee you an interview if you meet the minimum requirements for the post for
which you are applying.
If you are unable to meet all the requirements because of your impairment but feel they
are achievable with minimum adjustments, please explain below how you believe your
disability might be accommodated?




We do not discriminate on the grounds of race, gender, nationality, national origin, marital
status, disability, economic status, sexual orientation, age, trade union membership,
political or religious beliefs or responsibility for dependants.
                                                                                   Page 6 of 11
                       “ACME CARE LTD”
                        Personal Health Statement
This relates to any family medical or physical problems you may have or have experienced
in the past that could affect your ability to carry out the duties outlined in your job
description. This information is confidential and will only seen by your manager.
Please tick the appropriate boxes and comment on any areas relating to you.

MEDICAL.

        Conditions       Y/N                        Comments

      Heart Problems

       Skin Problems

        Headaches /
         Migraines
         Epilepsy /
        Convulsions

          Allergies


PHYSICAL

          Muscular

           Mobility

          Disability




MENTAL HEALTH PROBLEMS
      Compulsive
       disorders

        Depression

           Anxiety




                                                                               Page 7 of 11
                    Personal Health Statement (continued)
If you feel that a condition not listed in our questionnaire could affect your work in any way
please use the box below to state what your condition is and if you are on medication to
control it.




I declare I have not withheld any information which may influence my application for the
position described in the supplied job description.


Signature…………………………………………..Date……………………………..

Print Name…………………………………………………….




                                                                                     Page 8 of 11
                       “ACME CARE LTD”
                Registered Company Number 4150091

                  Rehabilitation of Offenders Act 1974
By virtue of the Rehabilitation of Offenders 1974 (Exceptions) Order 1974, the provisions
of Section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment
which is concerned with the provision of health services and which is of such a kind as to
enable the holder to have access to persons in receipt of such services in the course of his
normal duties. Your answer to the following questions should include both “current” and
“spent” convictions.

                   Have you ever been convicted of a criminal offence?

                                          YES / NO
                                     (delete as applicable)

  If you have answered “yes”, please include details (including applicable dates) below:




DECLARATION

I declare that I have answered the above questions honestly and fully and that I am not
aware of any physical or mental disability, which may, affect my working capacity. I realise
that any false or incomplete statement of my part will render me liable to disciplinary action
or dismissal.

I understand that my details will be submitted for a police check in relation to the
applicable Child Protection Legislation. My name will also be checked against the
“Protection Of Vulnerable Adults” register.


SIGNED……………………………………………DATE……………….
                                                                                    Page 9 of 11
                        “ACME CARE LTD”
               Registered Company Number 4150091
                           CRIMINAL RECORD CERTIFICATE

If the position you are applying for is listed in Schedule 1, Part 11 of the Rehabilitation of
Offenders Act Order 1975, Acme Care is entitled to ask Exempted questions as defined by
section 113(5) of the Police Act 1997 about you. From July 2002 Acme Care is required
by the Domiciliary Care Agencies Regulations 2001 to acquire a criminal record certificate
in relation to any person who is a care manager or domiciliary care worker.

This means that should your application be successful we will obtain from the Criminal
Records Bureau a criminal record certificate relating to you, before your appointment is
confirmed. You are, however, encouraged to tell us about your criminal record before we
obtain a criminal record certificate.

Having a criminal record will not necessarily bar you from employment with us.
Each case will be considered individually and will depend on the nature of the position
applied for, and the circumstances and background of your offences. Acme Care has a
written policy on the recruitment of ex-offenders and will supply a copy on request.
Acme Care observes the “Code of Practice for Registered Persons and Other Recipients
of Disclosure Information” published by the Criminal Records Bureau at www.crb.gov.uk
on behalf of the Home Office, and will supply a copy on request.


Declaration

“I declare that to the best of my knowledge, the information I have provided in this
application for employment is true and current.”


Signed:                                                        Date:


Please print name:




                                                                                   Page 10 of 11
                 “ACME CARE LTD”
                            Job Description
 Post: Personal Assistant


 Job Description:
 To provide care and assistance for clients with either physical / mental
 disabilities elderly and infirm throughout the Coventry area to live
 independently. To promote, establish and maintain an independent lifestyle
 whilst enjoying a mutual, equal relationship. To maintain an appropriate level
 of professional care while in the contracted hours.


 Description of responsibilities and duties.
 A. Each carer will be responsible and for carrying out the duties that have
    been agreed between the agency and our client.
 B. A record of all visits and duties is to be documented on time sheets and
    report sheets.
 C. To be aware of all policies and procedures.
 D. To assist where necessary in all aspects of care e.g. dressing, washing,
    toileting, drinks and snacks during the day, preparing / cooking meals and
    clearing away, laundry, shopping and home help.
 E. To work as part of a rota system which includes the need to work on bank
    holidays and statutory holidays, also to increase hours worked above
    normal to cover for other staff holidays and sickness.
 F. To have the ability to create stimulating activities outside the home
    environment and where necessary incorporating outside agencies.
 G. Applicants must be able to demonstrate an understanding of the rights of
    people to lead quality lifestyles.
 H. The applicant must be able to respond to a client’s personal care and
    support needs with regard to their privacy, dignity and respect.
 I. To demonstrate a positive attitude towards clients choices.
 J. To undertake any duties which may be reasonably requested from time to
    time.
 K. To have an understanding and be able to support clients preferences and
    to respect their opinions.
 L. Numeracy skills are required for cash handling i.e. collecting a client’s
    pension, shopping, bill paying etc.




ALL EMPLOYEES OF ACME CARE LTD ARE REQUIRED TO
COMPLY WITH THE COMPANY’S EQUAL OPPORTUNITIES
     POLICY WHEN UNDERTAKING THEIR DUTIES.


                                                                            Page 11 of 11

				
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