REGISTER – NationWide ExtraCare Services

APPLICATION FORM

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When are you available to start work?
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Title
Last Name:
First Name
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Sex :
Previous names/Maiden Name (if applicable) :
Equal Opps check:
Date of Birth:
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Current Address:
Postcode:
Home Tel No:
Mobile No:
National Insurance Number:
E-mail Address:
Do you have a UK Passport?
Do you need permit to work in the UK?
Passport No:
If yes, please provide your work permit / visa number:
Are you lawfully resident in the UK?
Are there any restrictions on your continued residence in the UK?
Are there any restrictions on your visa?
If yes, please state your home office / port reference number here:
If yes, please detail:
Visa expiry date (if applicable):
Do you have a full driving licence?
Is it clean?
If no, please give details:
Emergency :
Name of the person:
Relationship to you :
Address :
Do you have daily use of a car?
Phone Number:
Name of Bank / Building Society:
Sort Code:
Name on Account
Account No.
(if Ltd company, give company name)
Bank Address
Office Use:

REFERENCES

Contact Name:
Job Title:
Company Name:
Address:
Telephone Number:
Email

TRAINING / EDUCATION

Dates (from - to)
Educational Institution
Qualifications Obtained
VOCATIONAL SKILLS & COMPETENCE

EMPLOYMENT HISTORY

Current Employer Company Name
Dates of Employment
Job Title
Reasons for Leaving
Salary on Leaving
Notice Period (if relevant)
Duties / Responsibilities of the Role
Company Name
Dates of Employment
Job Title
Reasons for Leaving
Salary on Leaving
Duties / Responsibilities of the Role
DISCLOSURE AND BARRING SERVICES
DISCLOSURE AND BARRING SERVICES AND REHABILITATION OF OFFENDERS ACT (1974) DECLARATIONREHABILITATION OF OFFENDERS ACT (1975)Because of the type of work that you have applied for, the Rehabilitation of Offenders Act (1974) (Exemptions 1975 apply) imposes a duty on people who apply for social care positions to disclose any conviction that would otherwise be considered ‘spent’.
Have you been convicted of a criminal offence?
(if yes , please provide details)
Have you been given a conditional discharge for a criminal Offence?
(if yes , please provide details)
CRIMINAL RECORDS BUREAU DISCLOSURE CRIMINAL RECORDS BUREAU DISCLOSURE Before you can commence working as a Care Worker in the community, the Company must obtain a CRB clearance for you. You will have already completed the form and supplied documents that confirm your identity.The Company will keep the documentation under the terms of the Data Protection Act 1998. The CRB documents will only be checked by CQC Inspectors for inspection purposes under the Care Standards Act 2000 when the Company’s records are checked.
DECLARATION I GIVE MY CONSENT TO THE DISCLOSURE OF THE CRB DOCUMENTATION RELATING TO MY APPLICATION ONLY IN THE CIRCUMSTANCES DESCRIBED ABOVE. DECLARATIONI confirm that the information I have given is correct and that I have not withheld any information of which the company should be made aware. I also understand that giving any incorrect or misleading information could lead to my subsequent dismissal, or withdrawal /termination of assignment.

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APPLICATION FORM

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