Date Form Sent or downloaded: (office use ONLY)

CRB Ref: (office use ONLY)

Please provide
2 recent and
Disclosure No: (office use ONLY) Identical
Third Floor, West Point, Springfield Road
Horsham, West Sussex, RH12 2PD Passport size

Tel: 0845 601 4003 Fax: 01403 217827 photographs

info@country-cousins.co.uk www.country-cousins.co.uk

APPLICATION FORM
Forename(s) Title
Surname Birth Name
Present Address

Postcode:
Telephone No. (Home) Mobile No.
E-mail Address
Nationality Place of Birth
(Please provide a copy of your passport)

Passport No. Expiry Date:

Do you have permission to work in the UK. Yes ❑ No ❑
(If yes, please provide documentary evidence, i.e. Home Office letter - this is a requirement under the Asylum and Immigration Act 1996, Section 8)
(Please also provide a copy of your passport)

Nat Ins. No.

Home Address (If different)

Tel. No. (Day) Mobile No.

Emergency Contact
Name
Address

Tel. No Relationship:

Are you a driver? If yes, are you a manual or automatic driver?

Yes ❑ No ❑ Manual ❑ Automatic ❑
Do you hold a full clean driving licence? Yes ❑ No ❑ Expiry Date:
Do you have any current endorsements? Yes ❑ No ❑
If yes, please provide details:

Have you ever previously applied or worked through this agency:- (Please give dates where possible)
Applied: Yes ❑ No ❑ Worked: Yes ❑ No ❑
Any other Nestor Healthcare Group Company: Yes ❑ No ❑
,
FULL EMPLOYMENT HISTORY (Continue on a separate page if necessary or enclose a copy of your CV)
Please provide details of all employment, starting with your most recent. Please explain gaps, if any.
Please include caring for family or friends, both paid and unpaid employment.

Dates Name, address and Job Title and Date and Reason
From To telephone number of employer responsibilites for Leaving

Have you ever been subject to a formal investigation or under a disciplinary procedure in the workplace? Yes ❑ No ❑
If Yes, please give details:....................................................................................................................................................................
.............................................................................................................................................................................................................

EDUCATION, TRAINING AND DEVELOPMENT

Please detail any previous healthcare or medical training:..................................................................................................................
.............................................................................................................................................................................................................
.............................................................................................................................................................................................................

Please list any relevant courses you have completed, e.g. first aid, moving and handling, food hygiene: ................................................
.............................................................................................................................................................................................................
.............................................................................................................................................................................................................

ABOUT YOU
Is there any type of food that you would be unwilling/unable to prepare for Clients (e.g. meat, fish, dairy products)?
Yes ❑ No ❑ If yes, please specify: .............................................................................................................................

The duties you are asked to carry out will include the following. Please tick all tasks you are prepared to take on:-
1. Limited personal care ❑ 5. Preparation of meals ❑
2. Full personal care ❑ 6. Companionship ❑
3. Light Housework ❑ 7. Home Administration ❑
4. Shopping ❑ 8. Personal Laundry ❑

Please describe your hobbies and interests, with special reference to those which will help you in your chosen work as a
carer/companion:- ..............................................................................................................................................................................
.............................................................................................................................................................................................................
.............................................................................................................................................................................................................
Where did you hear about Country Cousins?
.............................................................................................................................................................................................................
When are you available to start a care assignment?
.............................................................................................................................................................................................................
REFERENCES
Please provide us with details of three referees.
NB All references will be verified by telephone so you must provide telephone contact details or your application will be delayed.

1. Employment - Your current or most recent employer

(you must have been employed by them for a minimum of 6 months - a professional address or company stamp is required)

2. Character - Someone who has known you for at least 3 years and is not related to you
(must be able to comment on your ability to cook, clean and run a home)

3. Additional Employment - If you have ever previously worked in a position involving work with children or vulnerable
adults, which lasted more than three months in duration, then we would also need to obtain a reference from them.

Referee 1 (Employment) Referee 2 (Character)

Name of referee:
Position held or relationship to applicant:
Establishment Address:

Post Code:
Contact Tel No:
Known From: To: Known From: To:

Referee 3 (Employment with children or vulnerable adults)

Name of referee:
Position held or relationship to applicant:
Establishment Address:

Post Code:
Contact Tel No:
Known From: To:

Criminal Records Bureau Disclosure

Have you ever been convicted of a criminal offence? Yes ❑ No ❑
Have you ever been cautioned? Yes ❑ No ❑
Have you any hearings pending? Yes ❑ No ❑
If yes, please give details: ....................................................................................................................................................................
..............................................................................................................................................................................................................
..............................................................................................................................................................................................................
Because of the nature of the work for which you are applying, this application is exempt from the previous section 4(2) of the Rehabilitation of Offenders Act 1974
(Exemptions) Order 1975. Applicants are, therefore, not entitled to withhold information about convictions which for other purposes are ‘spent’ under provisions of the
Act. Should your application be successful, any failure to disclose such convictions that have occurred, OR MAY OCCUR IN THE FUTURE, may lead to
termination of registration. If you are in any doubt whatsoever about a declaration, you must discuss this with the Cousins Selection Team. A conviction does not
automatically prevent you from registering, however, failure to declare, will lead to immediate action.

• I consent to the above information being checked against all Police and D.o.H records and am aware that any ‘spent’ convictions will be disclosed.
• I declare that I have never had a Criminal Conviction recorded against me in any Country that I have resided in.
• I declare that the information given above, is, to the best of my knowledge, true.

Declaration
‘I have completed/I am willing to complete an Application for a Criminal Records Bureau Disclosure and can further state that to the best of my knowledge and belief,
there will not be any positive disclosure made that will preclude me from working with vulnerable adults and children’ (PLEASE DELETE WHERE APPLICABLE).

I also give permission for a copy of the Disclosure to which I am subject, being made available upon written request to a named Authorised person, who acts on behalf
of the National or Local Government for auditing purposes’

Name: (please print) ...................................................................................

Signature: .................................................................................................... Date: ............................................

Data Protection
Under the Data Protection Act 1998 (“the Act”) we are required to provide you with certain information and to seek your consent
to the processing of personal data supplied by you on this form.

For the purposes of the Act the data controller in respect of personal data relating to you is Nestor Primecare Services Limited.
The purposes for which personal data supplied by you on this form are intended to be processed are as follows:-

• To assess your skills, suitability and eligibility to become a companion/carer

• If you subsequently are accepted as one of our companion/carers, to assist in introducing you to our clients.
• This may also include providing clients with copies of photographs for identification purposes of carers.
• To update you with relevant information

The personal data supplied by you on this form may also be disclosed to other approved third party companies in order to inform
you of training courses and additional benefits.

Please tick if you do not wish to be supplied with this information: ❑

We may retain certain personal data supplied by you on this form after you have ceased to be a Cousin in order to comply with
current legislation and client requirements.
Please sign this declaration to indicate your consent to the processing by the Company of the data supplied by you on this form.

Declaration
I consent to the Company processing all or any personal data supplied by me on this form or as a result of searches
made following and resulting from its completion, and to the disclosure and transfer of such personal data, for the
purposes described above.

Name: (please print) ...................................................................................

Signature: .................................................................................................... Date: ............................................

Agreement
I accept that under no circumstances will I make a private arrangement, financial or otherwise, with a client introduced to me by
the Agency. Nor will I effect an introduction of a client to a third party, without first informing the Agency, in order that the
Agency’s terms of business may be sent to that third party.

Name: (please print) ...................................................................................

Signature: .................................................................................................... Date: ............................................

WHAT HAPPENS NEXT?

WE WILL PROCESS YOUR APPLICATION FORM AND APPLY FOR REFERENCES ON YOUR BEHALF.

ON RECEIPT OF TWO OR MORE SATISFACTORY REFERENCES AND IF SELECTED TO ATTEND AN INTERVIEW, YOU WILL BE
CONTACTED BY A MEMBER OF THE COUSINS SELECTION TEAM TO ARRANGE A MUTUALLY CONVENIENT DATE, TIME AND
VENUE FOR THIS.

1) Please bring all originals of documents requested with you to the interview

2) You should bring with you any copies of appropriate training certificates, e.g.:-

• Carers Training
• Food Handling
• Moving and Handling
• First Aid
 EQUAL OPPORTUNITIES MONITORING QUESTIONNAIRE
We aim to ensure that no applicant receives less favourable treatment on the grounds of race, colour, ethnic and national origin,
religious belief, political opinion or affiliation, sex, marital status, sexual orientation, gender reassignment, age or disability, or is
disadvantaged by conditions or requirements which cannot be shown to be justifiable.

Our selection criteria and procedures are frequently reviewed to ensure that individuals are selected and treated on the
basis of their relevant merits and abilities. The information you provide will be used for statistical use only and will be treated
in the strictest confidence. The Business Centre based in Horsham will be able to help if you have any queries.

Personal Details (Please tick appropriate box)

Gender: ❑Male ❑ Female

Age: ❑ Below 25 years ❑ 26-36 years ❑ 36-45 years ❑ Over 45 years

Ethnic Origin:

White Mixed

❑ British ❑ White & Black Caribbean

❑ Irish ❑ White & Black African
❑ Any other white background ❑ Any other mixed background

Asian or Asian British Black or Black British

❑ Indian ❑ Caribbean
❑ Pakistani ❑ African
❑ Bangladeshi ❑ Any other black background
❑ Any other Asian background

Chinese or Other Ethnic Group If other, please specify:

❑ Chinese .................................................................................................

❑ Any other

Disability
Do you consider yourself to have a disability under the terms of the Disability Discrimination Act 1995? Yes _ No _
(Disability is defined as a physical or mental impairment, which has a substantial and long-term effect on someone’s ability to
carry out normal day to day activities).

If yes, please give details: ...................................................................................................................................................................

.............................................................................................................................................................................................................
.............................................................................................................................................................................................................

Please give details of any special arrangements you will need if invited for interview (e.g. sign language, special access
requirements) ......................................................................................................................................................................................
.............................................................................................................................................................................................................

Name: (please print) ...................................................................................

Signature: .................................................................................................... Date: ............................................