Job Application Form Please fill out the form to submit your job applications. Subject Surname First Name Other Name Home Address Contact Number Email NI Number Position Applied For Care ServiceDomiciliary Care ServicesLive-in CareCleaning ServicesSecurity ServicesCompanionship Do you have a DBS YesNo Is it on DBS update services YesNo Upload DBS (PDF only, max 1MB) Do you need work permit to work in the UK YesNo Your Referee (Must be from Employer & should contain name, tittle, organization and email) Your Second Referee (Should contain name, tittle, organization and email) Health Assessment Questions (Yes/No) Have you ever had asthma, bronchitis, or any other chest infection? YesNo Have you ever had any problems with your neck or upper arms? YesNo Have you ever had an episode of low back pain, sciatica, or lumbago? YesNo Have you ever had any skin trouble, including eczema or dermatitis? YesNo Have you ever had any type of diabetes? YesNo Have you ever had any hearing or visual problems? YesNo Have you ever had any allergies? YesNo Have you ever suffered from any fits, seizures, or epilepsy? YesNo Have you ever suffered from any psychiatric conditions (anxiety, stress, depression)? YesNo Have you ever experienced psychological or emotional difficulties? YesNo Any health condition or disability caused or worsened by work? YesNo Do you have any condition (physical/psychological) affecting daily function? YesNo Medically advised not to carry out certain work? YesNo Are you awaiting any treatment, tests, or investigations? YesNo Have you seen a doctor in the past year? YesNo Had any treatment/investigations in the past 2 years? YesNo Approximate number of sick days in the past 2 years: Do you consider yourself in general good health? YesNo Are you currently receiving regular treatment or medication? YesNo Have you ever had heart or circulatory disorders? YesNo Have you ever been drug or alcohol dependent? YesNo Retired or left employment due to ill health? YesNo Health problems from previous employment? YesNo Do you have any type of disability? YesNo Vaccination History: Tetanus YesNo Rubella (German Measles) YesNo Polio YesNo Tuberculosis YesNo Do you require any workplace adjustments? YesNo Health problems affecting ability to work night shifts? YesNo Ever denied a driving license on health grounds? YesNo Are you currently pregnant or breastfeeding? YesNo Covid-19 (current or recent case)? YesNo Why have you applied for this position: Upload Your CV (PDF only, max 1MB) Upload Your Certificate (PDF only, max 1MB) Additional Documents (PDF only, max 1MB) Δ
