Home Care APPLICATION FORM

APPLICANT
Title: Mr Surname: Parmar First Name:
Rahulkumar
Previous Surname: Position applied for: Home care Date: 26-05-2023

Home Tel:

Mobile Tel:07469672505

Email:rkumarparmar0@gmail.com

Please Provide 2 proof of address for DBS purposes, address must stretch over a 5
year period.
Full Address From To Full Address From To 10/08/2020
Current 10/08/2020 Previous 16/01/2020

58 Elmwood road 46 Shaggy Calf

Lane

Post SL2 5QF Post Code SL25 HH

Code

PERSONAL DETAILS
Age:22 Nationality:INDIAN
Date Of Birth: 11/01/2000
National Insurance no:TK765943D Do you Drive? NO
Do You Need a Work Permit: YES Do you hold a British passport: NO
Are you on a Working Holiday Visa: No Other: NIL

Please Send copy of your passport and or Visa, and 2 passport-sized photographs of yourself
QUALIFICATIONS (copies of all relevant certificates)
University/College Qualification obtained Date Qualified
University of parul Diploma in mechanical 15/06/2018

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RELEVANT TRAININGS ATTAINED
Organisation Certificate Achieved Date of Certificate

Professional references Professional Reference or Character Reference

Contact Name Contact Name
Organisation Organisation
Name Name

Organisation Address Organisation Address

Post Code Post Code

Tel. Tel

Email Email

AVAILABILITY / Hours of Work

Full time ☐ Part time ☐ Flexible time ☐

Type of work
Care Homes ☐ Residential Homes ☐ Day Care Centre ☐
Domestic ☐ Kitchen Assistant ☐ Domiciliary Care ☐
Hospital ☐ Cook ☐ Live in Care ☐
Hours Available Shift Time Other times Please specify
Long day ☐ 8:00 am to 8:00 pm
Morning Shift ☐ 7am to 2:30 pm
Afternoon Shift ☐ 2 pm to 9:30 pm
Night Shift ☐ 8:00 pm to 8:00 am
Other specify ☐

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NEXT OF KIN
Name Pradeep Relationship Friend
Address 4A Wexham road slough
Post Code SL2 5AU
Contact 07507614813 Email address Pradeepsinghh039@gmail.com
Numbers

GENERAL INFORMATION

How did you hear about us__Internet__________Name of Publication_Google_______

BANK DETAILS

Name of Account: Rahulkumar Parmar

Account no: 57922497

Sort Code: 04-00-75

EMPLOYMENT DETAILS AND TRAINING/VOLUNTARY EXPERIENCE

(Continue on separate sheet if necessary. Please provide details of your full work history, including
any vuluntary work, vacation, employment & college/university placements. It is important that you
provide details of any gaps in your employment.)
From To
MM/YYYY MM/YYYY
Details of Employers/Organisation Speciality / Duties

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ADDITIONAL INFORMATION TO SUPPORT YOUR APPLICATION

Have you done any short course in relation to the management / Supervision Social Work Settings?

NO
Are you currently under investigation or subject to disciplinary proceedings by a professional registration
body or employer, including in any other country?

NO
Have you ever been or currently being subject of any police investigation, including in any other country?

NO

DECLARATION OF CRIMINAL RECORD

NOTE: The Rehabilitation of Offenders Act. By virtue of the Rehabilitation of Offenders Act 1974
(exemptions). The provision of Section 4.2 or the rehabilitation of offenders Act 1974 do not apply to any
employment which is concerned with the provision of health services. You are not entitled to withhold
information about conviction, which for other purpose are spent under the provision of the act. Any such
information given will be treated completely confidential and will be considered only in relation to your
application for this post.

HAVE YOU EVER BEING CONVICTED OF A CRIMINAL OFFENCE NO

Has there ever been an safeguarding investigation against you. NO

If Yes Please provide details on a separate sheet.

I declare that the information given as above is, to the best of my knowledge, true.
I have read, understand and agree to the conditions of service of which I have being given a copy.
I acknowledge that this information may form the basis of a computerised personnel system
to which I will have access as determined by Data Protection Act 1984

DATE__26-05-2023_______________SIGNATURE. _________________________________

DISCLOSURE BARRING SERVICE (DBS)

Do you have a current Updated DBS Number? NO

Please enter the ref. number ________________________Date Issued______________

I Declare the statement on this form are true and complete to the best of my knowledge and belief, I am
aware that false statement may affect my application. If a change to my health status occurs I agree to
notify Allfor Care of the change immediately.

Signature……………………….Date…26-05-2023………
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 EQUAL OPPORTUNITY MONITORING
Allforcare is committed to the promotion of equality of opportunity in its employment policy, practices and
procedures. To help us implement and monitor this policy please could you provide us with the following
information

NAME: Rahulkumar parmar

I would describe my race or cultural origin as (please tick one box only)

BLACK CARIBBEAN BANGLADESHI WHITE BRITISH

BLACK AFRICA INDIAN OTHER (Please specify below)

CHINESE PAKISTANI ………………………………….

Gender (please Tick Appropriate box): MALE FEMALE

Is there anyone who relies on you for day-to-day care and attention? YES NO

If yes, are they:

Children age 0-4 5-11 12-16 Other family member or partner

Do you consider yourself to have a disability? NO

Defined Age Group 18-25 26-35 36-45 46-55 55+

This information will be kept separate from you application form and will be treated in the strictest
confidence.

Before a formal offer of appointment is made Allfor Care will verify details provided by the successful
candidate about present/most recent employment. The successful candidate will also have to produce
evidence of qualifications and a copy of their birth certificate.

I certify that the information given in support of my application is correct

Signature: .................................................... Date:………26-05-2023………………………

Please return the completed form to: Allfor Care

8 Clifton Rd
HA3 9NS
Kenton

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 OFFICE USE ONLY

Ensure this form is completed in full and submitted to the relevant admin/accounts department for processing.
Complete the form in BLOCK CAPITALS.

Mark the boxes where appropriate below

Staff has completed the following:

Shown how to fill timesheets Completed CRB/DBS

Care Plan discussed for relevant clients Staff Handbook

Given FORMAL instruction for shift times Given Care-for-IT Log In

Staff Full Name:

Staff Current Address:

Account Details
Bank, Account no and
Sort Code

Staff NI Number:

Staff Date of Birth:

Email Address:___________________________________________________________________

Date of first shift: ___________________________________

COMPLETED BY: __________________________ DATE: ___________________________

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