Join the CCA Team Title Name * First Name Last Name Gender Gender Male Female Other Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Applied For NI Number NI Number Nationality Next of Kin (In case of emergency) Relationship to you Phone (###) ### #### Do you hold a current driving licence? Yes No Do you have a car available? Yes No How did you hear about our CCA? 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 Please list the relevant training courses that you have attended including date and whether a certificate was issued: Please provide details of two persons from whom we may obtain references. One should be from your current employer / most recent employer and at least one should be relevant to care work Reference 1 Reference 2 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 If ‘yes’ to either of the above statements please give details on a separate sheet and place in a sealed envelope marked ‘for the attention of Mr W Pugh’ and deliver to the office. Thank you!
