Application form
First Name Surname
Maiden Name Title Mr Mrs Ms Miss
Address
Post
Code
Tel No Work
Tel
Email Address Mobile
Date of Birth Transport
Car M Cycle Bike
Full UK Driving Licence Y / N Endorsements Y / N
Endorsement details (if applicable)
Social care Registration Number
Current CRB number
Next of Kin
details
Name Relationship
Address
Post
Code
Tel No Mobile
Work
Preferences
What are your assignment preferences ?
Full time Part
time Weekends Evenings
Date you are available to work from
Geographical areas you prefer
Eligibility to
work in the UK
Nationality
If non British and non EU please complete the
following
Date of UK entry
Which travel documents do you hold?
Eu passport Work
Permit Working
Hol visa Ancestry/Patriality Visa
Other
Expiry date
Qualifications
Date College/University Qualification
Obtained
Courses
Attended & professional Qualifications
Date Details
Experience
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Team |
years |
Months |
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Adoption |
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Asylum |
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Child Disabilities |
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Child Protection |
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Children & Families |
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Fostering |
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HIV & Aids |
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Hospital |
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Mental Health |
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older People |
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Physical Disabilities |
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Substance Misuse |
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unaccompanied Minors |
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Youth Offending |
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Other |
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Professional
References
Name Tel
No
Job Title Fax
No
Address
Name Tel
No
Job Title Fax
No
Address
Employment
History
Please provide
details of previous employment, starting with the most recent
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Employer
/ Organisation |
Start
Date |
To |
Position
/ Grade |
Reason
for leaving |
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Declaration of
Health
Please supply details of your current GP
Name
Telephone Number
Address
Give details of any serious illness or operations you
have had
Date Details ongoing
effects/ Medication
Are you aware of any medical conditions that could
have a effect on your ability to carry out the required tasks in your day to
day work? Yes / No
If yes please give details
Are you currently on medication, or do you have any
medical condition that an employer should be made aware of? Yes /
No
If yes please give details
Criminal
Convictions
Due to the nature of the work for which
you are applying the provisions of section 4 (2) of the rehabilitation of
offenders act 1974 do not apply by virtue of the rehabilitation of offenders
act 1974 exceptions order 1975.
You are therefore NOT ENTITLED to
withhold information regarding convictions that are “spent” under the
provisions of this act; in the event of employment any failure to disclose such
information will result in the termination of your employment. Any information
given herewith will remain strictly confidential.
Have you ever been convicted of a criminal offence? Yes / No
If yes please give details
Do you have any criminal proceedings pending? Yes / No
If yes please give details
Do you give permission for Social Work Choices to
request a Criminal Records Bureau check? Yes
/ No
Social Work Choices Limited is commited
to providing you with a professional and unbiased service at all times. Any
information disclosed in this application will be treated as highly
confidential by Social Work Choices Ltd and all of its employees at all times
and the guidelines set out under the Data Protection Act 1984 will be followed.
Declaration
I declare that
the information disclosed in this application is true and correct.
Signed
Name
Date
Please return Application to Social Work
Choices Ltd
211 Pearl House, Anson Business Court, Staffordshire Technology Park, Stafford, Staffs,
ST18 0GB
Tel: (01785) 248880