SECTION 1 – APPLICANT INFORMATION

Title
First Name
Last Name
Previous Surname (If Applicable)
Email Address
Current Address
Town Postcode
Home Telephone Number
Mobile Number
Date of Birth
National Insurance Number
Driving Licence Yes ☐ No ☐
Position Applied For
Referred by (If Applicable)
How Did You Hear About The Vacancy?
Have you ever worked for Halo Yes ☐ No ☐
Informatics or Comfort Care Services or
Date From: Date To:
the Comfort Care Services Group?
If yes, please provide dates and location Location:

SECTION 2 – CURRENT OR MOST RECENT EMPLOYMENT

Company Name
Company Address
Employment Start Date Employment End Date
Reason for Leaving
Job Title
Job Duties Please provide CV
Notice Period (Where Applicable)
SECTION 3 – PREVIOUS EMPLOYMENT (1)
Company Name
Company Address
Employment Start Date Employment End Date
Reason for Leaving
Job Title
Job Duties Please provide CV
SECTION 4 – PREVIOUS EMPLOYMENT (2)
Company Name
Company Address
Employment Start Date Employment End Date
Reason for Leaving
Job Title
Job Duties Please provide CV
Please use additional page if required
SECTION 5 – SECONDARY AND FURTHER EDUCATION
This information can be provided at a later date
Place of Study Subject/Qualification Grade/Result Date Commenced Date Completed

SECTION 6 – OTHER PROFESSIONAL QUALIFCATIONS OR MEMBERSHIP BODIES

This information can be provided at a later date

SECTION 7 – OTHER TRAINING OR COURSES ATTENDED

This information can be provided at a later date

SECTION 8 – EXPERIENCE OF MENTAL HEALTH OR LEARNING DISABILITIES

SECTION 9 – REHABILITATION OF OFFENDERS ACT 1974

Please note carefully the following information:

The post you have applied for is exempt from the provisions of the Rehabilitation of Offenders Act 1974; therefore applicants
must disclose all criminal convictions which are regarded as ‘Spent’. The reason being is the nature of the work involved
(Substantial level of access to vulnerable adults) renders the post from section 4(2) of the Act in accordance with
Rehabilitation of Offenders Act 1974 (Exemptions) order 1975.

You are therefore required to give details of all convictions and cautions, including spent convictions. Any information that
you may give will be strictly confidential and will be considered only in relation to this or a similar position for which you may
be considered for at Halo Informatics.

Have you ever been convicted/cautioned of a criminal offence? Yes ☐ No ☐

Are you currently subject to any criminal proceedings or investigations? Yes ☐ No ☐
If Yes to either of the above questions, please give details i.e. date(s), offence(s) and outcome(s)
Please provide details here:
SECTION 10 – DECLARATION OF DISCIPLINARIES AND/OR INVESTIGATIONS RELATED TO
SAFEGUARDING
1. Have you ever been investigated for issues relating to Safeguarding? Yes ☐ No ☐
2. Have you ever been dismissed from a previous employer for issues relating to
Safeguarding?
Yes ☐ No ☐

3. Are you currently being investigated for any issues related to Safeguarding? Yes ☐ No ☐
If Yes to any of the above questions, please give details below i.e. date(s), incident(s) and outcome(s)
Please provide details here:

SECTION 11 – DISABILITIES DISCRIMINATION ACT 1995

This Act protects people with disabilities from unlawful discrimination, if we know you have a disability we will make
adjustments to the working arrangements or the working environment, providing it is reasonable in the circumstances to
do so.

Do you have a disability, which is relevant to your application? Yes ☐ No ☐

If yes, please state below the nature of this disability
Please provide details here:

Do you believe there are any reasonable adjustments we would make in order for you to
carry out the duties of your post?
Yes ☐ No ☐
If Yes, please provide additional information below
Please provide details here:

Do we need to make any reasonable adjustments for you to attend an interview? Yes ☐ No ☐
If Yes, please provide additional information below
Please provide details here:
 SECTION 12 – REFERENCE DETAILS
Please note we require BOTH Employment/Company and Personal References
Employment/Company Reference/s - Points to Remember:
 Company References must cover a 2 year period of employment, training or education
 You must provide an email address for each referee
 If you were/are a student or trainee this should include a teacher/tutor at your school/college or university
 Emails for employers must be a valid work email address and not the referee's personal email address
 All reference requests will be verified by Halo Informatics
 Please use additional sheet if required

REFEREE 1 – LAST OR PREVIOUS EMPLOYER REFEREE 2 – PREVIOUS EMPLOYER (IF REQUIRED)

Title Title
Referee Name Referee Name
Referee Job Title Referee Job Title
Address Address
Email Email
Start Date Start Date
End Date End Date

REFEREE 3 – PREVIOUS EMPLOYER (IF REQUIRED) REFEREE 4 – PREVIOUS EMPLOYER (IF REQUIRED)
Title Title
Referee Name Referee Name
Referee Job Title Referee Job Title
Address Address
Email Email
Start Date Start Date
End Date End Date

Personal Reference/s - Points to Remember:

 Your Personal Reference must have known you for a minimum of 2 years
 A character reference must not be from a relative
 Please use additional sheet if required

REFEREE 1 – PERSONAL REFERENCE REFEREE 2 – PERSONAL REFERENCE (IF REQUIRED)

Title Title
Referee Name Referee Name
How do you know How do you know
the referee? the referee?
Address Address
Email Email
Known for (years) Known for (years)

Do we have your permission to contact your previous employers and personal

reference/s, if you are shortlisted for an interview?
Yes ☐ No ☐
SECTION 13 – DECLARATION

I confirm that I have the right to work in Pakistan at the time of application.

I confirm that to the best of my knowledge the information supplied on this form is correct. I authorise Halo
Informatics to obtain employment, educational and personal references. I understand that providing false
information may render any offer of employment invalid or may result in my dismissal if employment is
commenced. I consent to Halo Informatics processing my application.

Signed: Date

Print Name
(Capitals)