Application form

Please use black font colour as this form may be photocopied

Name: Princess joy Butche
Position applied for: night carer
Service name
Service address
Date of application

Confidential application form

The information provided will be treated as confidential and will be processed strictly in accordance
with the provisions of the Data Protection Act 1998.
Disability Discrimination statement
If you are unable to meet some of the requirements specifically because of a disability, please tell us
about this in your supporting statement. If you meet all other criteria, you will be considered for an
interview. If following interview you are the best applicant for the post, we will explore with you any
possible reasonable adjustments as detailed in the Disability Discrimination Act 2005.

Please carefully read this form and answer all the applicable questions honestly and truthfully.
Afterwards read the declaration and Consent under the Data Protection Act at the end of the form
and sign and date it.

Applicants details

Title

National Insurance Number

First Name

Telephone (home)

Surname

Mobile

Address

Email Address

Postcode

Driving Licence
Yes
No

Details of current or most recent employment

Employers name

Job Title

Employers Address

Salary and benefits

Postcode

Reason for leaving

Start Date

Leaving date

Please provide a brief description of your current/most recent post. Tell us about your duties,
responsibilities, skills and experience relevant to the post you are applying for.

Employment History
Please provide all details of full employment history including all types of employment i.e. voluntary,
part time etc.
Please provide information in relation to any gaps in your employment
Dates of
employment

Length of
service

Employers
name and
address

Job Title

Salary

Reason for
Leaving

Qualifications
Qualification

Establishment name

Year of Award

Relevant training Courses

Title of course

Awarding body

Year

Additional information

Availability for work

If currently employed, how much notice will you have to give you current employer?

Is there any other reason why you would not be able to start work immediately if you were
offered the job you have applied for?
Yes

No

If Yes give details

Do you have any existing holiday commitments?

Yes

No

If Yes give details

Are you willing to travel during the course of your employment?

Yes

No

If No give details:

Do you have a clean Driving License?

Yes

No

If No please provide details

Safeguarding
Peninsula Autism Services and Support is committed to promoting the safeguarding and welfare of
people who use our services. The organisation requires that all its employees share this
commitment.
The rehabilitation of Offenders Act 1974 (Exceptions Order 1975)
Please complete the section below 1 or 2 which is relevant to the role you are applying for
1. Applicants for general post need to disclose details of unspent convictions. Please tick the
appropriate answer below:
Do you have any unspent convictions?

Yes

No

2. Applicants in positions where they may come into contact with children and vulnerable adults

must declare both unspent and spent convictions. Please tick the appropriate answer below:
Have you ever been convicted of any criminal offences, or received a police caution or a warning?
Yes

No

If yes please provide details of conviction(s) in a sealed envelope, attached to this application form.
If you are selected you will be required to apply for an enhanced disclosure with the Criminal
Records Bureau (CRB check)
Are you subject to any sanctions imposed by a regulatory body?
Yes

No

If yes please provide details in a sealed envelope attached to this application.

Are you disqualified from working with children or vulnerable adults?
Yes

No

Please note:
Failure to disclose information where asked for could result in subsequent dismissal or disciplinary
action if you were appointed.
Having a criminal record will not necessarily exclude you from employment.

References

Please provide us with 3 references of people we may approach for a reference for you.
These should include you present or most recent employer/ education facility if you have not been
in employment. A personal referee who is not a family member and who has known you for more
than 2 years, they should state the capacity they know you in and your suitability for the post.
(The organisation operates safe and best practice recruitment procedures. References may be sought
if you are shortlisted, prior to interview, unless you indicate otherwise.)

Referee 1
Name
Position
Company Name
Email
Telephone number
Address/Postcode
In what capacity does this person know you
How long have they known you?
Can a reference be sought prior to interview?

Referee 2
Name
Position
Company Name
Email
Telephone number
Address/Postcode

In what capacity does this person know you

How long have they known you?
Can a reference be sought prior to interview?

Referee 3
Name
Position
Company Name
Email
Telephone number
Address/Postcode
In what capacity does this person know you
How long have they known you?
Can a reference be sought prior to interview?

Asylum and Immigration

Are you legally eligible to live and work in the UK in accordance with the Asylum and Immigration Act
1996?
Yes

No

NOTE: Before any contract of employment can be offered to anyone subject to immigration control
we are required to check and copy certain documents under Section 8 of the Asylum and Immigration
Act 1996 as amended.

Supporting Statement
Please state what attracted you to the job you have applied for and why you think you are a suitable
candidate.
Use the enclosed job description to assist you in indentifying how you would meet the requirements
of the post

Equal opportunities monitoring information

Note: the information requested in this section is voluntary. We are requesting this information to
help us fulfil our obligations as an equal opportunities employer. We aim to recruit staff on their
suitability for the position advertised, without consideration of age, sex, marital status, disability or
ethnic origin. So we can monitor this policy it will help us if you fill in this section.
Your date of birth:
Your gender (sex):
Your ethnic origin (Please tick the appropriate
category):
9

White
Black African
Black Caribbean
Black other (specify)
Chinese
Other Asian (specify)
Other (specify)

Declaration
I declare that the information I have given on this form is correct and that any misrepresentation by
me may be sufficient grounds for my dismissal if I am employed. I give my permission for my
previous employer/s and any references given to be contacted.
Signed by Applicant:
Date:
Consent under the Data Protection Act 1998 - the information given to Peninsula Autism Services
and Support Ltd in this form will be processed only by Peninsula Autism Services and Support Ltd for
the purpose of considering your application for employment. If you are successful in your application
this form and the information in it will be retained in your HR file for such time as you are an
employee of Peninsula Autism Services and Support Ltd and for up to 6 years after the end of your
employment. Otherwise this form will only be retained by Peninsula Autism Services and Support Ltd
for so long as it is required in connection with your application. By signing this consent you give us
your express consent to retain and process all the information contained in this form and to transfer
it to countries outside the European Economic area if required.
Signed by Applicant:
Date:

10