• Personal Details
  • Education/Employment
  • Fitness to work/medical questions
  • Equal Rights/Declaration
  • CV and Cover Letter

Personal Details

Title

First name

Last name

Date of Birth

Email Address

Address Line 1

Address Line 2

City

Postcode

County

Contact Number

Additional Contact Number

National Insurance Number

Position Applied for

Are you a UK Citizen?

Next of Kin

Full Name

Relation

Address Line 1

Address Line 2

City

Postcode

Contact Number

If you have a disability, are there any arrangements which we can make for you if you are called for an interview and/or work based exercise?

If yes, please specify

Education History

Name of institution

Date from

Date to

Qualification/Cerfifications

Date of Qualification

Do you hold any further education/qualifications?

If yes, please specify

Employment History

This must cover the whole of your working life to date. State the reasons for any breaks in employment.

Current/Most recent employer

Role

Address Line 1

Address Line 2

City

Postcode

Date from

Date to (leave blank if currently still working there)

Reason for leaving

Salary

Do you have any further employment

If yes, please specify

Are there any gaps in your work history?

If yes, please specify

Reference 1

Current/Most recent employer

Full Name

Full Address

Contact Number

Email Address

Job Title

Reference 2

Previous employer to the one above:

Full Name

Full Address

Contact Number

Email Address

Job Title

Fitness to work

Do you have any issues that would impact your ability to undertake your assignment or do you require any additional support?

If yes, please specify

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?

If yes, please specify

If you are successful in the application would you require a work permit prior to taking up employment?

Rehabilitation of Offenders Act

Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 2.4 of the Rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are therefore, not entitled to withhold information about convictions which for other purposes are “spent” under the provisions of the Act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the Order applies and should be entered at the end of any particulars you give in support of your application. A copy of our written policies is available on request. A criminal record will not necessarily be a bar to obtaining a position.

Have you at any time been convicted of an offence?

If yes, please specify

Equal Opportunities

Gender

Age Group

Please select which best describes your ethnic origin:

Do you have a disability

If yes, please specify

Do you have any Armed Service/Public Duty commitments (e.g. are you a JP or Councilor, etc)?

Asylum and Immigration

The law requires Reigns Consultancy Ltd to ask you to prove your right to work in the UK. To do this we need to inspect original documents that show your right and we must also keep a copy of these. We must inspect the documents listed below and you may also have to give further documents to explain any changes in name (i.e. marriage, divorce or deed poll documents). If you have a document from list A then we do not have to ask you to show it to us again after you start a job with Reigns Consultancy Ltd. If you have documents from list B then, you will have to show us up to date documents throughout your employment with Reigns Consultancy Ltd. List A documents 1. A passport showing that you, or your child, is a British or UK citizen and has the right to live in the UK; or 2. A passport or national identity card showing that you, or your child, is a national of a European Economic Area country or Switzerland; or 3. A residence permit, registration certificate or document certifying or indicating permanent residence issued by the Home Office or the Border and Immigration Agency to a national of a European Economic Area country or Switzerland; or 4. A permanent residence card issued by the Home Office or the Border and Immigration Agency to the family member of a national of a European Economic Area country or Switzerland; or 5. A Biometric Immigration Document issued to you by the Border and Immigration Agency which indicates that you are allowed to stay indefinitely in the UK, or that you have no time limit on your stay in the UK; 6. A passport or other travel document endorsed to show that you are exempt from immigration control, allowed to stay indefinitely in the UK, have the right to live in the UK, or has no time limit on their stay in the UK; or 7. An Immigration Status Document issued to you by the Home Office or the Border and Immigration Agency with an endorsement indicating that you are allowed to stay indefinitely in the UK, or have no time limit on your stay in the UK, when produced in combination with an official document giving your permanent National Insurance Number and your name issued by a Government agency or a previous employer (e.g. P45, P60, National Insurance Card); or 8. A full birth certificate issued in the UK which includes the name(s) of at least one of your parents, when produced in combination with an official document giving your permanent National Insurance Number and your name issued by a Government agency or a previous employer (e.g. P45, P60, National Insurance Card); or 9. A full adoption certificate issued in the UK which includes the name(s) of at least one of your adoptive parents, when produced in combination with an official document giving your permanent National Insurance Number you’re your name issued by a Government agency or a previous employer (e.g. P45, P60, National Insurance Card); or 10. A birth certificate issued in the Channel Islands, the Isle of Man, or Ireland, when produced in combination with an official document giving your permanent National Insurance Number and your name issued by a Government agency or a previous employer (e.g. P45, P60, National Insurance Card); or 11. An adoption certificate issued in the Channel Islands, the Isle of Man, or Ireland, when produced in combination with an official document giving your permanent National Insurance Number and your name issued by a Government agency or a previous employer (e.g. P45, P60, National Insurance Card); or 12. A certificate of registration or naturalisation as a British citizen, when produced in combination with an official document giving your permanent National Insurance Number and your name issued by a Government agency or a previous employer (e.g. P45, P60, National Insurance Card); or 13. A letter issued by the Home Office or the Border and Immigration Agency to you which indicates that you are allowed to stay indefinitely in the UK, or have no time limit on your stay, when produced in combination with an official document giving the person’s permanent National Insurance Number and your name issued by a Government agency or a previous employer (e.g. P45, P60, National Insurance Card). List B documents 1. A passport or other travel document endorsed to show that you are allowed to stay in the UK and are allowed to do the work in question, provided that it does not require the issue of a work permit; or 2. A Biometric Immigration Document, issued by the Border and Immigration Agency to you which indicates that you can stay in the UK and are allowed to do the work in question; or 3. A work permit or other approval to take employment issued by the Home Office or the Border and Immigration Agency, when produced in combination with either a passport or another travel document endorsed to show that you are allowed to stay in the UK and are allowed to do the work in question, or a letter issued by the Home Office or the Border and Immigration Agency to you, or the employer or prospective employer confirming the same; or 4. A certificate of application issued by the Home Office or the Border and Immigration Agency to or for a family member of a national of a European Economic Area country or Switzerland, stating that you are permitted to take employment, which is less than 6 months old, when produced in combination with evidence of verification by the Border and Immigration Agency Employer Checking Service; or 5. A residence card or document issued by the Home Office or the Border and Immigration Agency to a family member of a national of a European Economic Area country or Switzerland; or 6. An Application Registration Card (ARC) issued by the Home Office or the Border and Immigration Agency stating that you are permitted to take employment, when produced in combination with evidence of verification by the Border and Immigration Agency Employer Checking Service; or 7. An Immigration Status Document issued by the Home Office or the Border and Immigration Agency to you with an endorsement indicating that you can stay in the UK, and are allowed to do the work in question, when produced in combination with an official document giving your permanent National Insurance Number and your name issued by a Government agency or previous employer (e.g. P45, P60, National Insurance Card); or 8. A letter issued by the Home Office or the Border and Immigration Agency to you or the employer or prospective employer, which indicates that you can stay in the UK and are allowed to do the work in question, when produced in combination with an official document giving your permanent National Insurance Number and your name issued by a Government agency or previous employer (e.g. P45, P60, National Insurance Card).

Consent and Confirmation Details

• It is my understanding that all the information given is to the best of my knowledge true and wilfully giving any information that l know to be untrue could result in disciplinary action or termination of my contract. • I am permitted to work in the UK. • I understand that my registration is subject to the receipt of at least two satisfactory referees and enhanced disclosure from CRB and confirmation of statutory qualifications/registration if applicable. • I undertake to inform Reigns Consultancy Ltd should I be convicted of any offence in the future. • I undertake to inform Reigns Consultancy Ltd immediately if I am engaged through their introduction including the offer of permanent employment following a temporary assignment. • I agree to respect the confidentiality of patients and any other information I may have access to at all times. • I am clear that Reigns Consultancy Ltd cannot guarantee assignments and that they have no responsibility whatsoever to pay for hours not worked no matter what the situation. • I have read and understood and agree to the “Conditions of work for flexible workers”, of which I have been given a copy. • I understand that Reigns Consultancy Ltd will make deductions from my wages if any money is owing as a result of over-payment and/or any other money outstanding to the company. • I am in a good state of physical and mental health. I understand that it is my responsibility to inform Reigns Consultancy Ltd immediately if there is a change in my medical condition that may affect my ability to do my work. Time Regulations 1998 (as amended) I consent in access of an average of 48 hours per week. I understand that I may withdraw this consent by giving Reigns Consultancy Ltd not less than 3 months notice. I understand that my registration with Reigns Consultancy Ltd can be terminated at any time following unsatisfactory reports. • I consent to my personal data being processed for recruitment and assignment purposes and compliance with the Domiciliary Care and Nursing Agency Regulations 2002. • I understand that the information will be entered on to our computer database under the terms and conditions of the Data Protection Act 1998 and will be treated in a secure and confidential manner. • I agree that health care is an occupation which happens 365 days a year and care workers will be expected to accept their share of work, on a Rota basis, of work at weekends and on Bank Holidays including Christmas at normal pay rates. • I accept that each care call is a self-contained offer of work. Once the care call is over I am not obliged to undertake any further care calls nor is Reigns Consultancy Ltd obliged to offer me any. On completion of any care call, I shall no longer be an employee of Reigns Consultancy Ltd. I agree that I am deemed to be served notice to terminate the employment created by each care call at the start of an assignment and I fully agree to waive any right to a longer period. • I agree that my place of work will vary depending on the work offered and accepted. My place of work may be any location of any service user’s home I agree to work. No allowance will be granted to me for any expenses or time incurred in travelling to and from the place of work allocated to me. • I agree that my continuous employment with Reigns Consultancy Ltd as a Home Support Worker starts on and ends with the completion of each care call.

Please select

CV

CV

Cover Letter

Cover Letter