Job Application Form

DATA PROTECTION STATEMENT – The information provided on this application form will be used for recruitment purposes only. If you are unsuccessful, the form will be retained for approximately 6 months and then destroyed. If successful, the form shall be filed on your personnel record and some of the information contained within may be used for administrative purposes.

Your Details

Title(Required)

if Other, please state

Name(Required)

First Last

Have you ever had a change of name?(Required)

Yes

No

If yes, what was the date of change(Required)

Previous Name(Required)

First Last

Mobile(Required)

Phone

Email(Required)

Date of Birth(Required)

Place of Birth(Required)

Marital Status

Are you legally entitled to work in the UK?(Required)

Yes

No

Address Details

Please provide your addresses for the last five years with dates of moving in/out

Current Address(Required)

Street Address Address Line 2 City County Post Code Country

Have you lived at this address for 5 or more years?(Required)

Yes

No

Moving in date(Required)

Previous Addresses

Please provide your previous addresses within last 5 years with the dates of moving and out.

Previous Address 1(Required)

From(Required)

To(Required)

Previous Address 2

From

To

Previous Address 3

From

To

Emergency Contact

Name(Required)

Relationship(Required)

Their Address(Required)

Their Phone Number(Required)

NI and Banking Details

National Insurance

Bank Name

Bank Address

Sort Code

Account Number

Do you have a Limited company?

Yes

No

Limited Company Owners

If you have a Limited Company please provide details below

Company Name

Company Registered Number

Company Address

Company PostCode

Equal Opportunities Monitoring Form

What best describes your gender?(Required)

Ethnicity(Required)

If you answered to other above please tell us your ethnicity

Religion(Required)

If you answered to other above please tell us your religion

Do you have any physical or mental impairments/disability?(Required)

Yes

No

If so, please state impairment:

Please provide details of what, if any, adjustments would be required in order for you to be able to carry out the job for which you are applying:

Declarations

I HAVE READ AND UNDERSTOOD THE FOLLOWING:(Required)

Terms & Conditions

Non-Solicitation(Required)

I agree

I agree that I shall not, within 12 months after the later of receiving details of a Care Seeker and last providing Care to that Care Seeker become employed or engaged (as an independent contractor or on any other basis) or offer to become employed or engaged, in any way by any Care Seeker identified by our service, whether to perform Care or for any otherreason, other than via Our Service and in accordance with the Terms and Conditions of Service to which I have agreed. If I am in breach of this, I shall disclose to Happiest at Home all details relating to the agreement between me and the Care Seeker and I shall make payment to Happiest at Home of a Fixed Fee of £4995.00. In the case where both the engaging and engaged parties are liable, this liability shall be joint and several.

Signature (Name)(Required)

Today's Date(Required)

Your Details

Address Details

Previous Addresses

Emergency Contact

Employment Details

Agreed Rates of Pay

NI and Banking Details

Limited Company Owners

Starter Checklist

Student Loans

Equal Opportunities Monitoring Form

Declarations