Employment Application Form
Please answer all the questions
Email address *
Date *
MM
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DD
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YYYY
Surname *
Your answer
First Name *
Your answer
Position Applied for
Your answer
Approximate Number of Hours Wanted
Your answer
Full Time / Part time *
Current Address *
Your answer
Please list all the previous addresses up to recent 5 years with start date and end date at each Address as we would need this information for a successful DBS check
Your answer
Telephone Number
Your answer
Own Transport (Yes / No) *
Do you have a Driving License *
Any Endorsements on your Driving License
Give Details of Endorsements
Your answer
Any relevant Training / Qualifications
Your answer
Name of School/College/University
Your answer
Qualifications Achieved ( Mention the recent one)
Your answer
Date of Qualification
Your answer
Location/Details
Your answer
Details of any other courses Attended
Your answer
Current Employment - Date Employed
MM
/
DD
/
YYYY
Current Employer - Nature of Business
Your answer
Current Employer - Position held and reason for leaving
Your answer
Current Employment - Salary/Rate
Your answer
Current Employment - Name and Address
Your answer
Previous Employment - Name and Address
Your answer
Previous employment - Date Employed
MM
/
DD
/
YYYY
Previous Employment - Nature of Business
Your answer
Previous Employment - Position held and reason for leaving
Your answer
Previous Employment - Salary/Rate
Your answer
DETAILS OF ALL YOUR EMPLOYMENT HISTORY since leaving school including month and year. Also, please indicate any GAPS in employment and the reason for these *
Your answer
Do you require us to make any special arrangements in order for you to participate in the recruitment process?
Your answer
GP Name *
Your answer
GP - Telephone Number *
Your answer
GP - Address *
Your answer
Next of Kin - Full Name *
Your answer
Next of Kin - Relationship
Your answer
Next of Kin Telephone Number *
Your answer
Next of Kin - Full Address
Your answer
NI Number *
Your answer
Current or Recent - Contact person name
Your answer
Current employer - Address
Your answer
Current employer - Telephone Number
Your answer
Current employer contact Email
Your answer
Name of Previous Employer to the one Above
Your answer
Previous Employer - Full Address
Your answer
Previous Employer contact email
Your answer
Previous employer contact number
Your answer
Character reference - Full Name
Friends or relatives are not acceptable referees
Your answer
Character reference - Address
Your answer
Character reference - Telephone Number
Your answer
Character reference - Relationship to you
Your answer
Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not and warnings and cautions in the space provided. If any additional please email us at hr@am2pmcare.com
Your answer
I have read, understood and agree with the below terms *
I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.I understand that I may not be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS.I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. By my signature, I authorise AM2PM Quality Care Limited to request a DBS Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred Care workers, or withdrawal of any registration required by my employment status.
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