Application Form

First Name

Surname (required)

Position Applied For

Home Address (required)

Postcode (required)

Telephone Number (home)

Mobile Number (required)

Email Address (required)

Do you hold a full clean current UK driving licence? (required)

YesNo

If you are in employment, what notice are you required to give your present employer? (required)

Do you consider yourself to be a disabled person? (required)

YesNoPrefer not to say

All disabled applicants who meet the essential criteria in the person specification will be shortlisted for interview and given the opportunity to outline any reasonable adjustment that may be required

If you are related to any employee of Natural Breaks Ltd pleas state their job role, together with name, address and relationship to this person (required)

Canvassing directly or indirectly will disqualify you

EMPLOYMENT

Present or most recent employment details

Name, full address and telephone number of employer

Job Title

Salary

Date of Appointment

Reason for and date of leaving

Main duties and responsibilities

PREVIOUS EMPLOYMENT

Please place your most recent employment first, include any voluntary work, and account for any gaps e.g. for periods of unemployment, child care etc. If your full employment history is not accounted for, you may not be shortlisted for interview.

Natural Breaks reserves the right to contact all or any employers you have listed below, in order to verify the employment details sorted.

Name, full address and telephone number of employer

From

Job title, main responsibilities and reason for leaving

Salary

Name, full address and telephone number of employer

Job title:

From

Main responsibilities and reason for leaving

Salary

Name, full address and telephone number of employer

From

Job title, main responsibilities and reason for leaving

Salary

QUALIFICATIONS - SECONDARY EDUCATION

Dates Attended to: (required)

Dates Attended from: (required)

NAME AND LOCATION OF SCHOOL/COLLEGE (required)

Qualifications (include date, level, grade)

FURTHER EDUCATION - university, college, part time or work related courses

Name and Location of Establishment

Dates Attended to:

Dates Attended from: (required)

Qualifications( include date, level, grade - where appropriate)

All information contained in this form will be treated as strictly confidential. By supplying information, you will also be indicating your consent to the information being processed for all employment purposes as defined in the Data Protection Act 1998, and any verification checks which may be made. However, we must protect the public funds we handle and so we may use the information you have provided on this form to prevent and detect fraud. We may also share this information, for the same purpose with other organisations which handle public funds. (Revised March 2004).

SKILLS AND EXPERIENCE

Using the person specification as a guide, please give details of any experience or skills which demonstrate your suitability for this post; this can include experience/skills gained in previous jobs or in other areas such as temporary work, voluntary wor (required)

REFEREES

Give details of two people to who you are not related and to whom reference can be made; one has to be your current employer, or if you are currently unemployed, your last employer, or in the case of school leavers, your tutor.

REFEREE 1

Name (required)

Job title

Telephone Number (required)

Address

Can we contact prior to interview (required)

YesNo

REFEREE 2

Name (required)

Job Title

Telephone Number (required)

Address

Can we contact prior to interview? (required)

YesNo

REHABILITATION OF OFFENDERS ACT 1974

The nature of the post means that you will be involved with vulnerable adults or children and therefore the post is exempt from the provisions of the above Act. It is necessary to disclose all convictions , cautions or court martial that you have had. Natural Breaks seeks Enhanced Disclosures with the Disclosure and Barring Service for all prospective employees. Failure to disclose may lead to the withdrawal of an offer of employment.

Have you ever received a caution, court martial or conviction for a criminal offence? (required)

YesNo

is there any court action pending against you? (required)

YesNo

If you ticked yes to either of the above please complete below. Any information will be treated confidentially and the possession of a conviction does not necessarily mean that you will not be short-listed for the post.

Date

Offence

Conviction/Pending Court Action

Date

Offence

Conviction/Pending Court Action

PROTECTION OF CHILDREN AND VULNERABLE ADULTS DECLARATION

The underlying principle in UK legislation and guidance relating to vulnerable adults and children is the welfare and safety of the individual is paramount. Natural Breaks therefore require all prospective employees to complete and sign the following:

1. Has any Social Service Department or Police Service ever conducted an investigation into any allegations of concerns that you may pose an actual or potential risk to children or vulnerable adult?

YesNo

2. Have you ever been convicted of any offence relating to children or vulnerable adults?

YesNo

3. Have you ever been the subject of any disciplinary process or been asked to leave employment/voluntary role due to inappropriate behaviour towards a child or vulnerable adult?

YesNo

I confirm that the above information given by me is correct and that I consent to my personal data being processed and kept for the purpose described above in accordance with the Data Protection Act 1998

Print Name: (required)

Signed: (required)

Date: (required)

DECLARATION OF PHYSICAL AND MENTAL FITNESS

Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and subsequent CQC Regulations all prospective employees are required to be physically and mentally fit to carry out the role.

Please complete the following statement

I, (print name) (required)

declare that I am physically and mentally fit for the purposes of the work as laid down in the job description

Sign Name:

Date (required)

PERMISSION TO WORK IN THE UK

Under section 8 of the Asylum and Immigration Act 1996, it is a criminal offence to employ anyone who does not have permission to work in the UK. All applicants invited to interview will be required to provide documentary evidence of their right to work in the UK. ALL APPLICANTS regardless of their nationality are required to complete this section.

Do you hold a valid passport for the United Kingdom? (required)

YesNo

Please sign and date where indicated. If no, please answer the following questions:

Do you have a valid work/residence permit or pre-settled/settled status for the UK?

YesNo

Please state the date your visa runs out

PLEASE READ BEFORE SIGNING

I declare that by signing this form I am stating that I am legally entitled to work in the UK with or without the necessary permission from the Home Office or any other relevant authority. if I have received permission I have included any copies of all relevant documentation. I acknowledge that if I am found to be working without the relevant permission, my employment will be terminated with immediate effect and details passed on to the relevant authorities.

Print Name (required)

Signed (required)

Date (required)

DECLARATION

I declare the information contained in this application form is to the best of my knowledge correct

Print Name (required)

Signed: (required)

Date (required)

All information contained in this form will be treated as strictly confidential. By supplying information, you will also be indicating your consent to the information being processed for all employment purposes as defined in the Data Protection Act 1998, and any verification checks which may be made. However, we must protect the public funds we handle and so we may use the information you have provided on this form to prevent and detect fraud. We may also share this information, for the same purposes, with other organisations which handle public funds. (Revised March 2004)

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