Premier Care Homes

Application Form
TITLE: Mr Mrs Miss Ms Other

SURNAME:

FIRST NAME(S):

MAIDEN NAME:

PRESENT ADDRESS:

EMAIL ADDRESS:

HOME TELEPHONE NO:

MOBILE TELEPHONE NO:

PERMANENT ADDRESS:
(If different from above)

GENDER: (Male or Female):

MARITAL STATUS: Married/Widowed/Divorced/Separated/Single

NATIONAL INSURANCE NUMBER:

POSITION APPLIED FOR: (Delete as appropriate)

Domestic/Laundry Assistant/Cook/Senior Care Assistant/Care Assistant/Nurse/Manager/Activities Co-ordinator

WORK LOCATION: Picktree Court / Durham House (Delete as appropriate)

ARE YOU INTERESTED IN PART-TIME OR FULL-TIME EMPLOYMENT?

Full-Time Part-Time

ARE YOU PREPARED TO WORK SHIFT PATTERNS, INCLUDING NIGHTSHIFT?

WHAT PREFERENCE OF DUTIES DO YOU HAVE?

Day Shift Evening Shift Night Shift No Preference

HAVE YOU PREVIOUSLY BEEN INTERVIEWED BY PREMIER CARE HOMES LTD AND/OR
OFFERED A POSITION WITHIN THE COMPANY?

WHAT WAS THE OUTCOME OF THE INTERVIEW/OFFER?

Premier Care Homes Ltd Application Form

PLEASE LIST ALL EDUCATION INCLUDING FURTHER EDUCATION:
Name of School / College / University Dates From Dates To

QUALIFICATIONS:
Name of School / Establishment Qualification Gained Date Awarded

LIST ALL TRAINING COURSES ATTENDED RELEVANT TO THE JOB YOU HAVE APPLIED
FOR:
Course Subject Date Taken Grade

EMPLOYMENT HISTORY ** Please attach a CV if available **

PRESENT OR MOST RECENT EMPLOYMENT:

Name of Employer:

Address of Employer:

Job Title:

Date Employment Commenced:

Weekly Hours/Shifts Worked:

Hourly Rate of Pay:

Notice Period:

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PLEASE INCLUDE ALL PREVIOUS EMPLOYMENT SINCE LEAVING FULL-TIME EDUCATION

The Care Homes Regulations 2001 require that you inform us of any gaps in your employment record as
part of this application for employment.

If there is insufficient space, please continue on a separate piece of paper and attach to this form:

Name of Employer Date Date Job Salary Reason for Leaving

Employed Employed Title
from: To:

IDENTIFY ANY SPECIFIC EXPERIENCE IN RESIDENTIAL CARE OR NURSING HOMES:

HAVE YOU EVER BEEN RELEASED FROM EMPLOYMENT FOR REASONS OTHER
THAN REDUNDANCY (YES / NO): IF YES, PLEASE INDICATE REASON FOR RELEASE:

REFERENCES:
Please provide the name and address of two referees. Your professional referee must be your current
employer or most recent employer if you are unemployed. Your personal referee must not be a relative.
Professional Reference Personal Reference
Title: Mrs/Ms/Miss/Mr Title: Mrs/Ms/Miss/Mr
Name of Referee: Name of Referee:
Company Name: Relationship to You:
Job Title: Length of Time has Known You:
Email Address: Email Address:
Address: Address:

Post Code: Post Code:

Tel No: Tel No:

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 PERSONAL HEALTH BACKGROUND

Present Health:

Date of last medical & result:

Are you currently receiving any treatment for any medical condition? YES / NO

Are you aware of any physical, mental or health reasons that would preclude or limit you from working
in a Care Home with Vulnerable Adults? YES / NO

Can you confirm that you are mentally and physically fit to do the job that you have applied for? YES / NO
(If no, please state the reason)

Can you confirm that you have received two doses of the COVID-19 Vaccination, and that you are able to
provide an NHS COVID Pass to evidence this? YES / NO

NURSING TRAINING/ QUALIFICATIONS: (If relevant)

Name and address of training school: Agency/Pin number:

Date of training: Number and Date of register/roll:

Proof of original GNC/UKCC certificates etc. is required to be seen before employment can commence.

POLICE CHECK & GENERAL

ARE YOU ABLE TO IMMEDIATELY LEGALLY WORK IN THE UK? YES / NO
TO LEGALLY WORK IN THE UK, DO YOU REQUIRE A VISA/WORK PERMIT? YES / NO
If yes, please provide details:

Note: we are legally obliged to ask you to provide evidence of your right to live and work in the UK.
HAVE YOU EVER BEEN CAUTIONED, REPRIMANDED, INVESTIGATED OR CONVICTED
OF A CRIMINAL OFFENCE? YES / NO If yes, please provide details:

ARE YOU CURRENTLY UNDER ANY INVESTIGATION FROM THE POLICE OR

SAFEGUARDING ADULTS TEAM OR WAITING TO GO TO COURT? YES / NO
If yes, please provide details:

*** Please note that, because of the nature of the work for which you are applying, this post is exempt from the
provisions of the Rehabilitation of Offenders Act 1974 (exemptions) order 1975.

Premier Care Homes aims to promote equality of opportunity for all with the right mix of talent, skills and potential.
Premier Care Homes considers applications from diverse candidates. Criminal records will be considered and taken
into account for recruitment purposes only. Due to the nature of work, you will be asked to disclose all convictions
which are ‘spent’ under the rehabilitation of Offenders Act 1974. Having an ‘unspent’ conviction will not necessarily
bar you from employment. This will depend on the circumstances and background to your offence(s).

As Premier Care Homes meets the requirements in respect of exempted questions under the Rehabilitation of
Offenders Act 1974, all applicants who are offered employment will be subject to a criminal record check from the
Criminal Records Bureau before a decision is made on suitability for employment and the appointment is confirmed.
This DBS check will verify and include details of cautions, reprimands and final warnings, as well as convictions.
** A Code of Practice sheet available from our umbrella organisation that establishes DBS documentation is available upon
request. **
Premier Care Homes Ltd - Application Form
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HOW MANY DAYS SICKNESS ABSENCE HAVE YOU HAD IN THE LAST 2 YEARS?
(PLEASE INCLUDE DATES AND REASON FOR EACH ABSENCE).

IS THERE ANY OTHER INFORMATION YOU WISH TO PROVIDE IN ORDER TO SUPPORT

YOUR APPLICATION FOR EMPLOYMENT WITH PREMIER CARE HOMES?

WHY DO YOU WISH TO APPLY FOR A POSITION WITH PREMIER CARE HOMES?

DECLARATION:

I DECLARE THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT AND
I UNDERSTAND THAT IT IS AN OFFENCE TO PROVIDE FALSE INFORMATION IN ORDER
TO GAIN EMPLOYMENT. I ALSO ACCEPT THAT PROVIDING DELIBERATELY FALSE
INFORMATION COULD RESULT IN MY DISMISSAL. BY SIGNING THIS DOCUMENT I
GIVE CONSENT FOR MY PERSONAL DATA TO BE USED FOR THE PURPOSES OF
RECRUITMENT AND POTENTIAL EMPLOYMENT IN LINE WITH THE COMPANY’S GDPR
POLICY.

SIGNED: DATE:

PRINT NAME:

Please return your completed application form to the Care Home that you are applying to:

The Manager HR Department

Premier Care Homes Ltd Premier Care Homes Ltd
Durham House Residential Care Home Picktree Court Care Home
Mains Park Road Picktree Lane
Chester le Street Chester le Street
Durham Durham
DH3 3PU DH3 3SP

Premier Care Homes Ltd - Application Form

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 EQUAL OPPORTUNITIES MONITORING FORM
PLEASE COMPLETE THE DETAILS BELOW. THIS INFORMATION WILL BE TREATED
IN THE STRICTEST CONFIDENCE AND WILL NOT BE USED AS PART OF THE SELECTION
PROCESS.

Surname:
First name(s):
Post Title:
Post Location:
Date of Birth: Age at time of application:

GENDER
Please tick one appropriate box below:

Male Female
Transgender

ETHNIC ORIGIN
Please tick one appropriate box below:

Ethnic Origin
White: British
White: Irish
White: Other
Mixed: White & Black Caribbean
Mixed: White & Black African
Mixed: White & Asian
Mixed: Other
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Bangladeshi
Asian or Asian British: Other
Black or Black British: Caribbean
Black or Black British: African
Black or Black British: Other
Chinese
Other Ethnic Group
Do not wish to disclose

DISABILITY
D1 Do you consider yourself to be disabled within the meaning of the Disability
Discrimination Act?

The Disability Discrimination Act defines a disabled person as someone with a physical or
mental impairment that has a substantial long term adverse impact on his or her ability to
carry out day to day activities.

Yes No
Do not wish to disclose

D2 Please tick any of the following that applies to you. You may tick more than one category.

Hearing impairment Reduced physical capacity, including

difficulty with physical co-ordination
Speech impairment Severe disfigurement
Visual impairment (not corrected by Mental illness
glasses or contact lenses
Reduced mobility Learning difficulties
Progressive condition (e.g.: cancer, Dyslexia
muscular dystrophy)
Other (Please specify)

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Do not wish to disclose

MARITAL STATUS
Please tick the box that applies to you:

Married Widowed
Single Civil Partnership
Divorced Do not wish to disclose

RELIGION, BELIEF AND NON-BELIEF

Please tick the box that applies to you

Christianity Judaism
Hinduism Sikhism
Islam Rastafarianism
Buddhism None
Other (please state below) Do not wish to disclose

SEXUAL ORIENTATION
Please tick the box that applies to you

Lesbian Bisexual
Homosexual Heterosexual
Do not wish to disclose

OTHER NEEDS
Is there anything else that we need to know to treat you fairly and equally?

HOW DID YOU HEAR ABOUT THIS VACANCY?

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