Employment Application Form

Updated: 03/2022

We are committed to promoting the equality of opportunity and welcome applications from anyone, who feels that they are able to carry out the duties, regardless of any previous experience, age,
disability, religious or cultural beliefs.

Position applied for:

Home Name:

First Name: Surname:

Other Names:
Address: Telephone numbers:
Home:
Mobile Number:
Work:
Postcode: (May we contact you at work? Yes/No)
Email address: National Insurance Number:
Are you related to any present or former employees of the Home/Company? Yes/No
If yes, please state relationship:

School/College: From: To: Qualifications: (Include dates and grades)

If you have undertaken any training or voluntary work to improve your employment prospects, please give details below:

THIS SECTION APPLIES TO NURSING ROLES ONLY

PIN Number:
 Yes No
Do you hold a current, clean driving licence?
If yes, how long have you held your licence for?

EMPLOYMENT HISTORY:
Please tell us about the jobs that you have had since you left full-time education, starting with your present, or most recent, job first.
A “full employment history” means a career history from the age of first employment, showing beginning and end dates (actual or approximated month and year), together with an explanation of periods of non-employment.
Individual placements within a continuous period of employment need not be listed.
If there are gaps in employment, please detail reasons for this.
For any previous roles which relate to health and social care, or working with children or vulnerable adults, we will contact your previous employers (if successful at interview)

Employer: Job title: Salary/Wages: From: To: Reason for leaving: Was this post within health/social care OFFICE USE ONLY
Any gaps in employment history to be or involved working with children or Verified and discussed
explained vulnerable adults? (to be signed off):

Yes: If ‘Yes’, please provide contact

details:

No:

Yes: If ‘Yes’, please provide contact

details:

No:

Yes: If ‘Yes’, please provide contact

details:

No:

Yes: If ‘Yes’, please provide contact

details:

No:
Yes: If ‘Yes’, please provide contact
details:

No:

Yes: If ‘Yes’, please provide contact

details:

No:

Yes: If ‘Yes’, please provide contact

details:

No:

Yes: If ‘Yes’, please provide contact

details:

No:

Yes: If ‘Yes’, please provide contact

details:

No:

Yes: If ‘Yes’, please provide contact

details:

No:
Any further information:

Please use this space to tell us about any other information that you feel would benefit your application, including any other skills you may have. Please feel free to continue on a separate sheet of paper if
required.

Declaration of Convictions/Disclosure of Information:

Successful applicants will be asked to provide disclosure information as required under section 113 of the Police Act 1997, and ISA Reference Number. Disclosure information will not be used
unfairly, and a criminal record will not necessarily be a bar to obtaining the position applied for.

No offer of employment will be withdrawn without discussion with the applicant.

Answer:
With the exception of minor motoring offences, have you ever received a formal caution/reprimand from the police or conviction from a court of law,
including if currently in progress, of any criminal offence?
If yes, please provide brief details and dates.

Are you legally entitled to work in the UK?

Are you a UK or Irish national?
If you are a non-UK or Irish national, please specify which nationality.
If you have/require a Work Permit or Visa, please provide details.
 Declaration (all roles): Yes/No/Non-
Applicable
I have previously worked within health and social care or with children or vulnerable adults
If answered ‘Yes’ to the above, I can confirm that during my employment within any of my previous roles (within health and social care or with children or vulnerable
adults) there have been no incidents of serious concern or allegations of suitability to work.
Note: As per Company policy, we will contact all previous employers within health and social care background in order to confirm applicants conduct whilst at work

REFEREES:
Please give us the details of two people who will provide us with a reference. One must be your last or current employer. If this is not the case, please tell us why not.
We will not contact your employer before an interview, but we will contact them before appointment to a role.

Name: Name:

Position: Position:

Organisation: Organisation:

Address: Address:

Postcode: Postcode:
Email Address: Email Address:

Telephone number: Telephone number:

Work: Work:
Other: Other:
Is this your current employer? YES / NO Is this your current employer? YES / NO
Are they related to you? YES / NO Are they related to you? YES / NO

Have you been referred to this post by one of our current employees (explain refer a friend scheme)? YES/NO
If ‘Yes’, please provide details of referrer
 1. Have you had the Covid 19 virus? YES/NO
If ‘Yes’, please provide approximate date/year below:

2. Have you had the Covid 19 vaccination? YES/NO                                       

If ‘Yes’, please give the date of first and second doses.
First dose:
Second dose:

I certify that the information given in this application is true and accurate to the best of my knowledge. I understand that if I am appointed and information is subsequently found to be false, I may be
dismissed.
Print Name:
Signature:
Date:

Nellsar will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to Nellsar holding the information contained within this application
form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider
this period over when a candidate accepts our job offer for the position for which we are considering you).
When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles. We have privacy policies that you can request for further information. Please be assured your
data will be securely stored by the Home Manager and only used for the purposes of recruiting for this vacant post. You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw
consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Home Manager or Privacy Officer on 01992 781 836.