Name *

First Name

Last Name

Gender

Gender

Male

Female

Other

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Do you hold a current driving licence?

Yes

No

Do you have a car available?

Yes

No

Please specify what type of work you require, please tick all that apply..

Part Time

Full Time

Days

Nights

Either

Are you currently employed?

Yes

No

If no how long have you been unemployed?

0-6 months

6-11 months

12-23 months

over 36 months

Please tick the relevant boxes for the types of client groups you have worked with:

Nursing homes

Residential homes

Supported living (adults)

Supported living (children)

Behaviours that challenge

Domiciliary care (home care)

Live-in care

Rehabilitation of Offenders Act 1974 By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) order 1975, the provision of Sections 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of certain 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/her normal duties. Your answer to the following question should include any “spent” convictions. Do you have any convictions or cautions?

Yes

No

Are you currently the subject of any criminal proceedings (for example charged or summoned but not yet dealt with) or any police investigation?

Yes

No