Application Form - ROC Northwest

Your Details

Full Name *

Position Applied For *

Job Reference / Care Home Location *

Date of Application *

Preferred working Pattern (Please choose) *

Full Time
Part Time
Bank

Please state where you learned of this vacancy

Personal Details

Surname *

Forename/s *

Title *

Preferred Name

Are you now, have you ever been, or were you at birth known by a different name? if so can you date when the name changed? Please give details:

Name

Used From

Used to

Name

Used From

Used to

Place of Birth *

Born outside the UK? If so please give date you moved *

Nationality *

Are you required to have a work permit? (Please Choose) *

Yes
No

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please provide the last 5 years of address including dates with months and years:

Date from(month/year)

Date to(month/year)

Date from(month/year)

Date to(month/year)

Date from(month/year)

Date to(month/year)

Date from(month/year) (copy)

Telephone *

Mobile

Your email address *

National Insurance Number *

Do you hold a full current driving licence?

YES
NO

Please indicate number of penalty points on licence (if any) *

If yes, date passed

DBS – Are you apart of the update service? *

Health

Have you been absent from work (other than for annual leave) for more than five days in the last twelve months? (Specify below) *

YES
NO

Do you require a work permit for employment in the UK? (Specify Below) *

YES
NO

Do you have any disability/injury/health problems, which may require special arrangements for the interview process? (Specify below) *

YES
NO

Do you have any disability/injury/health problems, which may require support or adaptations for employment? (Specify below) *

YES
NO

Have you ever been dismissed from employment for a reason other than redundancy? (Specify below) *

YES
NO

Have you ever been suspended or subject to disciplinary action? (Specify below) *

YES
NO

If you have answered yes to any of the above, please give details below.

Safeguarding Children

Have you ever been disqualified from working with children? *

YES
NO

Has your conduct in relation to children ever been a cause for concern or investigation? *

YES
NO

If yes to either question please provide details

Education / Training / Qualifications

Types of education, i.e. Secondary School/College/University Please state actual establishment

Date From MM/YY

Date To MM/YY

Qualifications Gained (State Level)

Grades

Dates

Types of education, i.e. Secondary School/College/University Please state actual establishment (copy)

Date From MM/YY

Date To MM/YY

Qualifications Gained (State Level)

Grades

Dates

If more then please detail here

Relevant non-qualification courses attended within the last 5 years:

Organising body

Course Title

Date From MM/YY

Date To MM/YY

Organising body

Course Title

Date From MM/YY

Date To MM/YY

If more then please detail here

Employment

Please provide a full employment history since leaving school. Account for all gaps in your employment record including any periods of unemployment and /or college/ university attendance. ROC Northwest Ltd reserves the right to contact any previous employer.

Current Employment

Name of Employer *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone Number *

Nature of Business *

Job Title *

Present Salary *

Date of Appointment MM/YY *

Notice Required *

Brief Description of Duties

Employment History / Volunteer History

Please fill in all fields stating all previous employment (including dates) since leaving school. If there are any gaps in employment due to being a full time parent, study, travel, unemployment, caring for a family member etc. just mark the reason and the dates. Please request an additional sheet if needed.

Date Left School (MM/YY) *

Employer – Location - Job Title *

From (MM/YY) *

To (MM/YY) *

Employer – Location - Job Title

From (MM/YY)

To (MM/YY)

Employer – Location - Job Title

From (MM/YY)

To (MM/YY)

If more then please detail here

Other Information

Criminal Convictions Declarations (Rehabilitation of Offenders Act 1974)
Details of Criminal Record

As all posts within the Company will involve contact with vulnerable children, you are required to disclose details of any criminal record and declare all convictions and cautions whether or not they would be spent under the Act. Only relevant convictions and other information will be taken into account, so disclosure of a criminal record may not necessarily be a bar to obtaining this position.

Please tick the appropriate box

Have you ever been convicted of a criminal offence? *

YES
NO

Do you have any criminal charges pending? *

YES
NO

If answering yes to the above questions, fill in the attached form and enclose in the envelope provided marked private and confidential and ensure this is returned as part of your application.

(Note that the post you have applied for is exempt from the Rehabilitation of Offenders Act 1974; this means that all convictions, cautions, reprimands and final warning on your criminal record must be disclosed).

Consent (Sign & Date)

I give consent for a confidential check to be made by ROC Northwest Ltd if I am offered the post.

Please note: Entering your name and date here gives us your consent. This acts as your signature.

Full Name *

Date *

DBS Check

Please complete if you have registered with the DBS update service

I have registered with DBS Update Service in the last 12 months and consent to ROC Northwest Ltd carrying out a status check

Full Name

DBS Certificate Number

Date

Have you ever worked or lived outside the UK for a period of more than six months? (Please list countries, reason for stay and dates below)

Country

Reason for Stay

From (MM/YY)

To (MM/YY)

Country

Reason for Stay

From (MM/YY)

To (MM/YY)

If any more then please list

N.B. All disabled applicants who meet the essential criteria in the person specification will be interviewed and given the opportunity to outline any reasonable adjustment that may be required.

References

One reference must be obtained from your current or most recent employer. Contact will be made prior to interview. References will be used as part of the short listing process. If you do not wish us to contact your present employer prior to interview, please provide an alternative referee who can comment on your work performance.

Please ensure you provide 2 referees. Please provide full address including postcode, telephone number and email address.

Name *

Position Held *

Organisation Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone *

Email *

Please tick here if you do not wish your present employer to be contacted prior to interview

Tick Here

Please supply any other names and contact details for all roles you have had working in a care setting or where you have worked with vulnerable adults or children.

Name, Address, and contact details of Employer

Position Held

Do you have any family members or relations who have worked or who are existing employers within the company?

Yes
No

If yes, please state

Experience / Supporting Information

Please give details of any previous experience, paid or unpaid which you consider provides evidence of your abilities for the post for which you have applied.

Declaration

I declare that the particulars given in this application form are true to the best of my knowledge. I understand that giving false information will be considered as a fundamental breach of trust and may lead to withdrawal of my application or disciplinary action including dismissal if I should be successful in obtaining this appointment. I acknowledge that this information may form the basis of a computerised personnel system to which I will have access as determined by the Data Protection Act 1984.

Full Name *

Date *

Reference Consent

Following changes in Data Protection Laws, all applicants must give permission for ROC Northwest Ltd to request references.
Our policy is that we must request a reference from every care provider you have worked for to ensure there have been no safeguarding issues. When requesting a reference we will use your full name, Date of Birth and National Insurance number in order to obtain an accurate reference. Please complete and sign the below agreement if you agree to a reference check.

Permission to Conduct a Reference Check

I authorise ROC Northwest Ltd to obtain references in connection with my application

Full Name *

Date *

To stop spam please enter the answer to the question *

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Submit your application

Your Details

Personal Details

Health

Safeguarding Children

Education / Training / Qualifications

Employment

Current Employment

Employment History / Volunteer History

Other Information

Please tick the appropriate box

Consent (Sign & Date)

DBS Check

References

Experience / Supporting Information

Declaration

Reference Consent

More complex assessments and ongoing therapies can be negotiated if it is felt the young person requires these services.