HK-CARE CONSULTING LIMITED

Application form

HK-CARE CONSULTING LIMITED

POSITION APPLIED FOR: (please state below)

Personal (to be completed in black ink only):

Mr/Mrs/Miss/Ms: ____________________ Surname: ________________________________________________

Forename: ______________________________________ Middle Name: ___________________________________

Previous surnames: ________________________________ Country of birth: ________________________________
Date of birth: ______________________________________ Male/Female: _________________________________
Address:________________________________________________________________________________________
_________________________________________________________________Postcode:_____________________
Tel No: ____________________________________ Mobile No: ___________________________________________
Email address:_______________________________________ NI NO:_____________________________________
Emergency contact Name: _______________________________Relationship:_______________________________
Contact Tel No: _______________________________________________
Do you hold a full driving licence: Yes/No if yes licence no: ______________________________________________
Details of any endorsements: _______________________________________________________________________
If you do not drive what transport do you have access to: Bus/Bicycle/motorcycle/other? (please state)

Work experience:
What areas of work have you had experience in? (Please tick relevant areas)
Terminal care Acute hospital (NHS) Children’s unit at children’s care home
Psychiatric units Learning difficulties Challenging behaviour
Community hospitals Autistic client’s residential homes
Domiciliary care Supported Living
Nursing homes Adult hospice

Please state hours you are looking for: ____________________________________________________per week

The law requires us to offer you a minimum of 5 hours per week reviewed every three months at which point we are
obligated to offer you the average of what you would have worked with us in those three months.

Education history and qualifications including professional qualifications from Secondary School.

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YEAR FROM-TO SCHOOL/COLLEGE/UNIVERSITY QUALIFICATIONS/ RESULTS

SUBJECTS ATTAINED

Previous experience: Please provide your work experience from when you left school explaining any gaps fully.
YEAR FROM -TO Company name and Brief description of Reasons for leaving
address responsibilities

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Tell us of any gaps and what you were doing at the time.

Please state briefly why you are interested in this job?

Please provide details of two referees (one character referee and one professional from a previous employer. If you
do not have a previous employer a non-relative professional will suffice e.g. teachers, doctors, coaches):

Referee 1 Referee 2
Name : Name:

Address: Address:

Tel No: Tel No:

Email address: Email address:

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NMC Pin Number (nurses only):_______________________________________________________________

Expiry date: _______________________________________________________________________________

Revalidation date if known?__________________________________________________________________

Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974
(Exceptions) (Amendment) Order 1986 provides that people in employment which is concerned with the provision of
care or who carry out their duties wholly or partly on the premises where such provision takes place are obliged to
disclose any convictions which would otherwise be spent. The Care Home Regulations provide that people in
employment which is concerned with the provision of care or who carry out their duties wholly or partly on the
premises where such provision takes place are obliged to disclose any criminal convictions, conditional discharges,
bind overs or cautions that they have been subject to at any time in the past.

Your answer to the following question should include any ‘spent’ convictions, conditional discharges, bind-overs or cautions. The
‘Company’ actively promotes equality of opportunity for all as stated in its Equal Opportunities policy, which can be found in your
handbook or at your local office.

Have you ever been convicted of a criminal offence or received a Police

Conditional discharge, bind-over, caution, warning or reprimand? Yes No

Have you ever been issued with a Penalty?

Notice for Disorder? Yes No

If so, please state below what was the offence &Date?

Making a false statement or any attempt to conceal information regarding this declaration will lead to the rejection
of your application for employment with this company. Any details provided will be treated in the strictest
confidence and will not automatically exclude anyone from being considered for any vacancy.

DECLARATION
I have completed an Application for a Criminal 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 or
children.

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

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Name: ______________________ Signature: ____________________

Date: ______________________

Do you have an online registered DBS? YES NO

Do you have a P45? If yes, please submit this with the pack.
If yes please provide DBS number:

Date of birth:

DECLARATION

I confirm that I am eligible to work in the UK / if accepted, all checks completed, will be eligible to work in
this organisation, within the United Kingdom. I fully accept that I am applying for Employment within HK-
Care Consulting Limited in the full knowledge and understanding that should HK-Care Consulting offer an
introduction to a Service User, and I accept such an introduction, any services that I provide, which are not
allocated through HK Care, are provided as a self-employed person. As a self-employed person, I accept
that HK-Care’s duty is that of an agent, not employer, and in signing this disclaimer I acknowledge that
neither HK-Care nor its employees hold any responsibility or liability whatsoever for the services I provide,
nor for the consequences of the provision of such services, including personal accident, damage to Service
User’s property if performed outside of the organisation rules and standards as provided etc.

I declare that all the information given is true and I understand that any false or misleading information
may result in my removal from HK Care’s register of applicants. I consent to the processing of sensitive
personal data as referred to on the front page of this form.

Print Name:

Signed:

Date:

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