Application Form - Home Care

Application Form - Homecare

- Step 1 of 11

Congratulations on your successful interview! We look forward to welcoming you to the Better Healthcare Team and getting you started for this exciting journey ahead. In order to get you one step closer, please select ‘next’ to complete your online form.

Date *

Branch - please select *

Applying for the post of *

Sector - please select *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone

Mobile Phone *

Email *

Confirm Email

Marital Status *

Single
Married
Divorced
Widowed
Civil Partnership
Other

Passport Number *

National Insurance Number *

Employment History

If this is your first job please enter in the following fields:

'Name and Address of Present Employer' - FIRST JOB
'Position held' - IF YOU HAVE DONE ANY UNPAID WORK IN RELATION TO CARING FOR SOMEONE PLEASE GIVE DETAILS
'Date from' - TODAY'S DATE

Name of present (or most recent) employer and role *

Position held *

Employed date from MM/YY *

Employed date to MM/YY

Do you have any previous employers to add?

Previous Employers

Full employment history explaining any gaps - please use additional sheets if necessary

If there is not enough room to type all in the cell, please continue to type as everything entered will show when the results are submitted.

Prev employer & role *

Position held by you *

Employed from MM/YY *

Employed to MM/YY *

Reason for leaving *

Prev employer & role (2)

Position held by you (2)

Employed from MM/YY (2)

Employed to MM/YY (2)

Reason for leaving (2)

Prev employer & role (3)

Position held by you (3)

Employed from MM/YY (3)

Employed to MM/YY (3)

Reason for leaving (3)

Prev employer & role (4)

Position held by you (4)

Employed from MM/YY (4)

Employed to MM/YY (4)

Reason for leaving (4)

Do you need to add more employment history?

Prev employer & role (5)

Position held by you (5)

Employed from MM/YY (5)

Employed to MM/YY (5)

Reason for leaving (5)

Prev employer & role (6)

Position held by you (6)

Employed from MM/YY (6)

Employed to MM/YY (6)

Reason for leaving (6)

Special Interests / Additional Comments

What is the main quality that you have that would enhance the experience that Service Users have from the Agency?

Referees

Must be your line manager, we require references for your previous 5 years and they must be continuous

Reference 1

Referee Name *

Position

Organisation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile (if known)

Worked From MM/YY

Worked To MM/YY

Type of Reference

When can we approach this referee

Reference 2

Referee Name *

Position

Organisation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile (if known)

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Type of Reference

Reference 3

Referee Name

Position

Organisation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile (if known)

Worked From MM/YY

Worked To MM/YY

Type of Reference

When can we approach this referee

Reference 4

Referee Name

Position

Organisation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile (if known)

Worked From MM/YY

Worked To MM/YY

Type of Reference

When can we approach this referee

Do you need to add more references?

Referee Name

Reference 5

Position

Organisation

Phone

Mobile (if known)

Worked From MM/YY

Worked To MM/YY

Type of Reference

When can we approach this referee

Referee Name

Reference 6

Position

Organisation

Phone

Mobile (if known)

Worked From MM/YY

Worked To MM/YY

Type of Reference

When can we approach this referee

Have you previously worked for another employment/nursing agency?

Please state the name of the agency

Ethnic Origin

Choose one section, then tick the appropriate box to indicate your cultural background

White

British
Irish
Any other White background

Other please state

Mixed / Multiple ethnic groups

White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background

Other please state

Asian / Asian British

Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background

Other please state

Black / African / Caribbean / Black British

African
Caribbean
Any other Black / African / Caribbean background

Other please state

Other ethnic group

Arab
Any other ethnic group

Other please state

Right to Work in the UK

I confirm I am entitled to work in the UK on the following basis:

Right to Work

I am a UK Citizen
I hold a valid work permit
I hold a Working Holiday Visa
I hold an Ancestral Visa
I am eligible to work in the UK under my spouses Visa
I hold a Student Visa
Other

Please select one

Other - please specify

Date from

If from birth, please enter your date of birth

Date to

Is your partner, any member of your family or household employed by the company?

Is your partner, any member of your family or household employed by the company? *

Name

Job Title

Branch

Transport

Do you have a current driving license? *

Do you have your own transport? *

Rehabilitation of Offenders Act 1974

By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, 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 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 question should include any ‘spent’ convictions.

Have you ever been convicted of a criminal offence? *

Please give details below

Have you ever been convicted of a criminal offence?

Data Protection Consent Form (GDPR)

I hereby give my consent to Better Healthcare Services to process the following information about me:

• Name
• Date of Birth
• Contact details, including telephone number, email address and postal address
• Experience, Staff Performance, training and qualifications
• CV
• National Insurance Number
• Payroll / Tax
• Bank Details
• GP Details
• Next of Kin Detail
• Passport
• Driving License
• Right to Work in the United Kingdom/ Visa
• Proof of references

Sensitive Personal Detail

• Disability/health condition relevant to the role
• DBS / Criminal conviction
• Disciplinary Information
• Religion
• Ethnic Origin

Contact

• I am happy to be contacted by email, text message, phone or post

I consent to Better Healthcare processing the above personal data for the following purposes:

Where I have delivered care on behalf of the company, I also consent to the Company processing my personal data with third parties for the purposes of internal audits and investigations carried out on the Company to ensure that the Company is complying with all relevant laws and

obligations - this includes CQC, local authority, NHS. Managed Service Providers and clients within the care industry.

The consent I give to the Company will last for 3 years or 6 years (from the time I leave Better Healthcare) where I have worked as a carer.

I am aware that I have the right to withdraw my consent at any time by informing the Company that I wish to do so.

Data Protection Consent Form *

Data Protection Consent - I hereby give my consent

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry

Declaration

I affirm that the information set out in this form is true and correct, is not misleading and that no material information has been omitted. I understand and agree that if I submit any false or misleading information or omit any material information this may result in an offer of employment being withdrawn or, if I have already
I understand and agree that I have read the conditions of Better Healthcare Services and agree to be bound and comply with the same.
I confirm that under the General Data Protection Regulation (GDPR) 2018, I hereby give my full consent to Better Healthcare Services to verify all the information given on this form and to process the information as described above under 'Data Protection Consent'.
I have read and understood the Standard/ Enhanced DBS Check Privacy Policy for applicants (this can be found in our Policies and Procedures file or on the Better Healthcare web site under 'downloads' www.betterhealthcare.co.uk/downloads
I agree to abide by Better Healthcare Services's Polocies and Procedures

Declaration *

I confirm the declaration above

Proof of ID and Address

You will need to send copies of your proof of ID and Proof of Address. These must be from the lists below. You can either take a photo and email them to your recruiter of use the below to submit electronically. You will need to tick which documents you will either be emailing over or uploading so we have a record. Any questions just call your recruiter.

Proof of ID - please choose 2 (one must be photo ID) *

Passport
Driving License
Birth Certificate
Citizens Card
Work Permit

Proof of ID

Click or drag files to this area to upload. You can upload up to 2 files.

Proof of Address - please choose 2 (must be within the last 3 months) *

Energy Bill
Bank Statement
Phone Bill (Landline)
Credit Card Statement
P45 / P60

Proof of Address

Click or drag files to this area to upload. You can upload up to 2 files.

If you are unsure of your NI number you can find it from this HMRC site:

https://www.gov.uk/government/publications/national-insurance-get-your-national-insurance-number-in-writing-ca5403

All successful applicants will be subject to a DBS (Disclosing and Baring Service) at a cost of £60 which is non refundable. However if you have a current portable DBS, please bring this along as this can be accepted.

Declaration

Declaration *

I declare that the information on this form is true to the best of my knowledge. Further, I understand that if I should be found to knowingly make a false statement regarding my medical history either in answering the above questions or to the Company's Director of Quality and Training, or should I conceal any material fact, the Company can terminate my contract without notice.

Comment

Employment History

Previous Employers

Referees

Reference 1

Reference 2

Reference 3

Reference 4

Ethnic Origin

Right to Work in the UK

Is your partner, any member of your family or household employed by the company?

Transport

Rehabilitation of Offenders Act 1974

Data Protection Consent Form (GDPR)

Declaration

Proof of ID and Address

Declaration

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