NEW APPLICATION FORM

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                                                                   ZionDomCareLtd
                                                         112a High Street, Slough Berkshire SL1 1JQ
                                                                 Tel. 01753 531 619 Fax. 01753 534 827.


APPLICATION FORM FOR EMPLOYMENT

The Employer is an Equal Opportunity Employer, which makes employment decisions regarding prospective
qualified employees without regard to race, colour, sex, religion, national origin, age, disability, marital status or
sex change status or any other factor protected by law.

PLEASE ANSWER ALL QUESTIONS NEATLY


Position applied for:…………………………………………………………                                                                                           Date:………………………………..


Where did you hear about this vacancy?.................................................................................................................




PERSONAL DATA

Surname………………………………………………First names……………………………………………………………

Address…………………………………………………………………………………………………………………………

When did you move at this address:……………………………………Tel no……………………………………………….

If you have been at this address for less than 5 years write down your addresses at the back of this form indicating the
dates.

Do you require a work permit to take employment in the U.K?                                              Yes                              No   


Date of birth:……………………………………Place of birth…………………………………………………………….


Nationality.............................................passport no............................N.I no.................................


Current occupation......................................................................................................................


EDUCATION & TRAININGS
  Qualifications                                                   Institution                                                       Dates
                                                                                                               2
                      You may continue on a separate sheet.




                      EMPLOYMENT HISTORY

                       EMPLOYER                    POSITION               PERIOD        REASON FOR LEAVING




                      YOU MAY CONTINUE ON A PLAIN PAGE


Application for Em
       REFERENCES

           1.   From more recent employer

           Name of company…………………………………………………. Name of referee………………………………………………….

           Position:…………………………………………………………… Tel no……………………………………......................................

           Address……………………………………………………………………………………………………………………………………

           2.   From a professional

           Name of referee…………………………………………………….Occupation……………………………………………………….

           Address…………………………………………………………………………………………Tel no…………………………………


       ATTENDANCE

       Have you ever had any serious illness or injury?       Yes   No

       If yes, please provide details:…………………………………………………………………………………………………..

       Are you registered as disabled?   Yes     No
       Have you any health problems or physical disabilities?       Yes    No

       Do you require any adjustments or special arrangements to be made when attending for interview?   Yes
          No
                                                                                                                                                          3

If yes, please provide details:……………………………………………………………………………………………………


Are you interested in working:               Part time         Full time

Are there any days, shifts, hours you will not work?                    Yes         No

If yes, please provide details:………………………………………………………………………………………………….

Can you meet the attendance requirements of the position?                            Yes        No

If selected yes, When will you be able to start work? .................................................................................................


CRIMINAL RECORD

Do you have a criminal record?                Yes        No

This does not apply to convictions which are spent under the Rehabilitation of Offenders Act 1974.

(Note that a ‘Yes’ answer does not automatically disqualify you from employment, since the nature of the offence,
date and the job for which you are applying are also considered.)

          If yes, please describe the conviction(s) fully, listing the dates and nature of the offence(s):



Have you previously submitted an application to the company before?                               Yes        No

If yes, month and year and position applied
for:……………………………………………………………………………….

List any relatives currently employed at the company and their relationship to you




DRIVING RECORD: (Only if licence is required for the position for which you are applying)

Do you hold a valid British driver's licence?                 Yes         No                                Licence no..............................

Is it subject to any endorsements?                Yes                No

          If yes, please provide details:

COMMENTS ( Please write any comments you wish to make to support your application)
                                                                                                                    4




EQUAL OPPORTUNITY MONITORING FORM

Job title: ………………………… Department:……………………………………                                        Full time       Part time

Zion Domicillary care is committed to a policy of equal opportunities in employment. In order to monitor the
operation of this policy, it is necessary to collect information from all job applicants and employees on the key
characteristics which relate to equal opportunity in employment.

The information collected will form a confidential record which will only be used to monitor the operation of the
employers Equal Opportunities Policy. This information is requested on a separate form and it will not be seen or
made known to selector.

Please mark the following boxes with a tick and delete any words as appropriate.

1.      Gender:                     Female           Male

2.      Date of birth:    ……………………………..

3.      Marital status:             Married/live with partner         Single/divorced/widowed

4.      No. of dependants:          Dependent children                other dependants

5.      Ethnic Origin:
        Please read the list below and tick the appropriate box that you feel most nearly describes your ethnic
        origin:

                          ASIAN                                            BLACK
           Bangladeshi              Chinese                           African          Caribbean

           Indian                   Pakistani                         Other – please describe


           Other Asian – please describe :

                          OTHER

           White

           Any other ethnic group – please describe :


6.      Are you registered disabled?                            Yes   No
                                                                                                                                    5




HEALTH QUESTIONAIRE

Please answer the questions below by placing a tick in the appropriate column. If your answer is Yes, please give details in the space
provided or continue on a separate sheet, if necessary.

 Please answer the questions below by placing a tick in the appropriate column. If your answer is Yes, please give
 details in the space provided or continue on a separate sheet, if necessary.

  Over the last 5 years have you had any medical/surgical conditions (excluding maternity leave) which
  have required treatment for longer than 1 month?

  Do you currently have a medical condition for which you have not sought the help of a health
  professional?

  Varicose veins or DVT

  Do you have any speech, hearing or visual difficulties?

  Have you ever had a drug or alcohol problem?


  Do you have any speech, hearing or visual difficulties?


  Do you intend to work night duties on a regular basic?
  Do you smoke? If yes please give daily amount.


  How many unit of alcohol do you drink per week?
  One unit = half pint beer, or 1 glass wine or 1 shot of spirit

  Are you pregnant? This question is asked to ensure only that any health needs of pregnancy are
  addressed, and to avoid any hazard or risk to a developing baby.

  If you have ever suffered from the following ailments/illnesses please give details of the dates, duration
  and outcomes in the space provided;
  Yes                                             No                                    Details with dates

  Rheumatism or arthritis

  Asthma, bronchitis or chest complaints

  Blackouts, epilepsy, fits or attacks of giddiness

  Back or neck problem

  Dermatitis or other skin problems.(such as psoriasis

  Chest pain, heart condition or raised blood pressure



  Typhoid, paratyphoid or dysentery

  Dermatitis or other skin problems.(such as psoriasis)


 Yes                                                No                                        Details with Dates
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 Do you consider yourself to be in good health?

 Have you had any health issues identified during an assessment in any Occupational Health Department?


 If Yes, were you passed fit without any medical restrictions imposed on your conditions of work?


 Have you ever been retired on medical grounds or had to give up work due to ill health or injury?


 Do you consider yourself to be disabled? (The Disability Discrimination Act 1995 defines disability as: a physical or
 mental impairment which has a substantial and long term adverse effect on the ability to carry out normal day to
 day activities.)



 Have you had more than 2 week’s sick leave continuously over the past two years? (Please state reason for
 absence and duration of absence)

 Are you currently suffering from medical or surgical condition for which you are receiving treatment and/or awaiting
 a medical/surgical appointment? (Treatment includes physiotherapy, psychotherapy counseling, etc. If on
 prescribed medication, please give details.




Please use this space to provide any medical information about you, which you think could affect your ability to
work within the health and social services environment, and for which you may require support




Signature of Applicant: ……………………………………                      Date: …………………………….




                    Thank you for your co-operation completing this form. Please return this form to:
                                                     Henri Frivet
                 112a High Street Slough Berkshire SL1 1JQ . Tel 01753 531 619 Fax. 01753 534 827



FOR OFFICE USE ONLY:

Date received……………………………

References No 1 contacted date……………………………….. References no2 contacted date……………………………..

CRB application date…………………………………………..CRB application result ………………………date………………………

OUT COME OF APPLICATION……………………………………………………………………………………………………………

STARTING DATE …………………………………………….Leaving date………………………………………………………………

COMMENTS:
7