Office 12, Marble Hall, 80 Nightingale Rd. Derby, DE24 8BF

enquiry@shilohealthcare.com

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Comprehensive Application Form

Applying for: Care Coordinator

CONFIDENTIAL: Please complete all sections of this form in block capitals if printing, or ensure all required fields are filled if submitting online.

Role Information

Post Applied for: *

Please indicate which business the role is for? *

Dome Care

Supported Living

Complex Care

Live-in Care

Where did you hear about us? *

1. Personal Details

Title: *

Surname: *

Forenames: *

NI No: *

Email: *

Full Address: *

Postcode: *

Home Tel No:

Mobile Tel No: *

Next of Kin

Title:

First Name:

Last Name:

Address:

Telephone:

Postal Code:

2. Additional Information

3. Criminal Record Declaration

Exemption from Rehabilitation of Offenders Act 1974

The nature of the work you are applying for is exempt from the provisions of the Rehabilitation of Offenders Act 1974. Offers of employment are subject to a satisfactory enhanced DBS check. It is therefore a requirement that all previous convictions are declared, even those regarded as 'spent'.

Have you ever been convicted of a criminal offence? *

Yes

Have you ever received any official cautions, reprimands or warnings? *

Yes

Are you currently the subject of any criminal proceedings/investigations? *

Yes

If you answered yes to any of the above, please provide details (including driving offences):

4. Education, Training & Qualifications

Secondary Education:

Qualifications/grades obtained:

Further/Higher Education:

Qualifications/grades obtained:

Other relevant training, professional qualifications or work-related skills (including dates):

Membership to professional bodies (include details/offices held):

5. Employment History

Current / Most Recent Employment *

Employer's Name: *

Job Title: *

Start Date:

End Date (if left):

Address:

Postcode:

Tel No:

Final pay / salary:

Reason for leaving:

Brief description of duties and responsibilities: *

Full Employment History

Please list most recent first, with any gaps explained.

Details of Employment Gap

Please provide details for any gaps in your employment or education history lasting one month or more.

6. Relevant Experience

Please use this section to state how your skills, experience and training would enable you to meet the requirements of the role for which you are applying. Please make reference to the person specification. *

7. Availability

Days	Mornings	Afternoons	Evenings	Sleep Over	Wakeful Nights
Weekdays
Saturday
Sunday

8. References

Please provide names and contact details of referees. The first must be your present or most recent employer.

Minimum of 2 references required. Personal referees (relatives, friends, neighbours) ARE NOT acceptable.

Reference 1: Current or Last Employer

Company Name:

Referee’s Name & Position:

Address:

Postcode:

Tel No:

Email Address:

Relationship to you:

Reason for leaving:

Contact prior to interview?

Yes

Reference 2: Previous Employer / Agency

Company Name:

Referee’s Name & Position:

Address:

Postcode:

Tel No:

Email Address:

Relationship to you:

Reason for leaving:

Contact prior to interview?

Yes

9. Declaration

The information in this form is true and complete. I agree that any deliberate omissions, falsification or misrepresentation on this form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This equally applies to any medical questionnaires I may complete.

I confirm that I have not been subject to any cautions or convictions (other than those given above), investigation, disciplinary action, or enquiry into adult/child protection matters or inappropriate behaviour, and that the information I have given is to the best of my knowledge correct.

I confirm the information provided is correct and I agree to the declaration above. *

You must agree to the declaration before submitting.

Date of Application: *

By typing your name earlier in the form, and ticking the declaration box, you are signing this application electronically.