northerncare - Because every child is individual

Please complete the form below. All fields marked * must be filled in for a successful submission.

You can alternatively fill out a word document.

northerncare Application Form 370Kb

Completed forms can be emailed to:

recruiting@northern-care.co.uk

or sent to:

northerncare HR Department
214 Whitegate Drive
Blackpool
Lancashire
FY3 9JL

Which Job do you wish to apply for?

Personal Details

Last Name:*

Title :

D.O.B *

Forename(s):*

Preferred Name:

Home Address:*

Postcode: *

Telephone No.: (Daytime)*

(Evening)*

Mobile:

E-mail:*

National Insurance No: *

If appointed is a work permit required?

Yes No

Are you related to any person employed by, or connected with northerncare?

Yes No

Name

Job Title

Relationship

Direct/indirect canvassing in relation to this application will render you liable to disqualification

DATA PROTECTION ACT
The information provided within this application may be used for statistical analysis and to obtain references from past and current employers. For applicants joining northerncare, the information provided will be used to administer company operations in connection with their employment. Unsuccessful applications will be destroyed after six months.

PRESENT (or LAST) EMPLOYER

Date From: D M Y

Date To: D M Y

Name & Address

Position Held

Current/Last Salary

Reason for leaving or wishing to leave current/last employment:

Notice Required:

CURRENT PAY SCALE & SPINAL COLUMN POINT (e.g. NJC/TEACHERS CPS)

Please give a brief description of current duties and responsibilities

EMPLOYMENT HISTORY:
This Is Required From Leaving School

Date From: D M Y	Date To: D M Y	Name and Address	Position Held / Reason For Leaving

TIME BREAKS IN EMPLOYMENT
Please provide details of any time not spent in employment or education, including periods of unemployment

Date From: D M Y	Date To: D M Y	Details

EDUCATION
Short listed candidates will be asked to provide original certificates where relevant

Date From: D M Y	Date To: D M Y	School/College/Uni Exams Taken & Subjects studied	QualificationGained

OTHER TRAINING:
- PLEASE GIVE DETAILS (E.G SHORT COURSES, RELEVENT SPECIALIST TRAINING)

Name and Address of Training Organisation	Title of course Attended	Date Attended

COURSES IN PROGRESS:- PLEASE INDICATE DETAILS OF COURSES CURRENTLY BEING UNDERTAKEN

Name and Address of Place of Course	Course Title	Period of Study

FURTHER INFORMATION IN SUPPORT OF YOUR APPLICATION

Please state your reasons for applying for this post and give details of any career objectives (continue on a separate sheet where necessary)

How do your experience, skills and/or knowledge at work or in a personal/voluntary capacity relate to the post for which you have applied? Please include details which support your ability to meet the essential requirements of this post

LEISURE INTERESTS (Please give brief details of interest, membership of clubs etc

DRIVING LICENCE

Do you hold a full current driving licence?	Yes No
Have or have you had any driving convictions/penalty points in the last three years?	Yes No

CRIMINAL CONVICTIONS

Do you have any criminal convictions spent or otherwise?***

Yes No

*** The post for which you have applied is defined as exempted employment within the terms of the Rehabilitation of Offenders Act 1974 (Exemption) Order 1975, as amended. You are therefore required to declare any convictions that have been imposed on you, whether or not they would, in terms of the Act, be classed as spent. Declaration of any convictions will not necessarily bar you from employment. This will depend on the circumstances and background to your offence(s). All applicants who are offered employment will be subject to a criminal record check before the appointment is confirmed. This will include details of cautions, reprimands or final warnings as well as convictions.

REFERENCES:- Current or Most Recent Employer And Former Employer

Name:*		Name:*
Job Title:*		Job Title:*
Address:*		Address:*
Post Code:*		Postcode:*
Telephone No.*		Telephone No.*
Email		Email:
Capacity in Which Known:*		Capacity in Which Known:*
Permission to Contact	Yes No	Permission to Contact	Yes No

DECLARATION

I understand that appointment to this post is conditional on the information supplied with my application being correct and that if I have withheld any information or any information is found to be false, I will be liable to disciplinary action.
The statements made by me in this application form and on any additional sheets are true to the best of my knowledge and belief.

I hereby consent to the processing of the above data in accordance with the current Data Protection legislation.
Should I be selected I will undertake any training including NVQ or other formal qualification required for the position applied for.

I accept the contents of this Declaration

Please note if we do not contact you within 4/6 weeks of the published closing date (or in the absence of a closing date, within 4/6 weeks of the date on which you submitted your application), then you have not been short listed for an interview. All applicants’ details are kept on file for 6 months and considered for future vacancies within northerncare as and when they may occur.

In the meantime may we take this opportunity to thank you for your application and for your interest in northerncare.

EQUAL OPPORTUNITIES
northerncare wholeheartedly supports the principle of equal opportunities and opposes all forms of unlawful and unfair discrimination on the grounds of colour, race, nationality, ethnic or national origin, sex, marital status, disability, sexual orientation, religious, or belief, age. As part of this process, we need to monitor our recruitment process. It would be very helpful if you could complete the following information which relates only to monitoring purposes and is not used in the selection process. This information is treated as confidential.

On receipt it will be separated from the application form before short listing takes place.

Section 1 – Sex

Female Male

Section 2 – Date of Birth

Section 3 – Marital Status

Single Married Divorced
Separated In Civil Partnership

Section 4 – Ethnic Origin

White – British
White – Irish
White – Other please specify

Mixed – White/Black Caribbean
Mixed – White/Black African
Mixed – White/Asian
Mixed – Other please specify
Asian (or Asian British) – Indian
Asian (or Asian British) – Pakistani
Asian (or Asian British) – Bangladeshi
Asian (or Asian British) – Other
Black (or British Black) – Caribbean
Black (or British Black) – African
Black (or British Black) – Other
Chinese
Other please specify

Section 5 – Disability Status

Do you consider that you have a physical or mental impairment which has a substantial impact on your ability to carry out normal day to day activities and which has lasted or is likely to last at least 12 months?

Yes No

If yes, what is the condition and are there any adjustments which you require at work?

Section 6 – Religion or Belief

Bahai
Buddhist
Christian
Catholic
Jewish
Muslim
Parsi
Rastafarian
Sikh
Other please specify

northerncare
DISCLAIMER FORM

The Disqualification for Caring for Children Regulations 2002 applies to anyone employed in a registered or voluntary children’s home.

The Regulations set out grounds for disqualification from caring for children.

These fall into three main areas:

1. Where a child of the individual has at anytime been the subject of a care or similar order, or where an order has been made with the purpose of removing a child from the individual’s care or preventing the child from living with him/her.

2. Where the person has been convicted of an offence specified in Schedule 1 of The Children and Young Persons Act or one involving injury or threat of injury to another person.

3. Where:

• The person has been concerned with a voluntary or registered children’s home which has been removed from the register; or

• An application by the person for registration of a voluntary or registered children’s home has been refused; or

• The person has been prohibited from being a private foster parent, or the person has been refused registration to be a child minder or provider of day care, or had his/her registration cancelled.

I have read and understood the above and declare that I am not disqualified from caring for children under The Disqualification for Caring for Children’s Regulations 2002.

I accept the contents of this Disclaimer Form

HEALTH

1) Do you have a physical, mental or sensory impairment which could:
a) Impede your ability to attend for interview or otherwise effect you during the recruitment process?	Yes No
b) Impede your ability to carry out various duties of the job for which you are applying	Yes No

If you have answered ‘Yes’ to (a) or (b) above, please provide relevant details and confirm any reasonable adjustments which you believe the Company could make to its recruitment arrangements, working arrangements or the physical features of its premises which would help facilitate your attendance at interview and/or help you overcome any disadvantage you may face.

How many days have you been absent from
work due to sickness over the past twelve months?.

DECLARATION

• I understand that northerncare may need to obtain further information from my doctor, or a hospital doctor whose advise has been sought, and I will be advised of my rights under the Medical Records Act 1998 should this become necessary.
• I also understand that northerncare may request that I undergo a medical examination.

I accept the contents of this Declaration

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