Application Form

Zanta Healthcare Ltd - Staff Application Form
ZANTA HEALTH CARE Ltd
ZANTA HEALTH CARE Ltd
Savoy Centre, Unit 4, Northfield Rd, Dudley DY29ES
Tel: 01384 913223 | Email: zantahealthcare.co.uk | http://www.zantahealthcare.co.uk

APPLICATION FOR ENTRY ONTO REGISTER OF CARERS

All fields are optional. You can submit the form with as little or as much information as you wish.
Job applied for Job reference no
Type of contract applied for:

PLEASE NOTE: WE WILL NEED TO SEE THE ORIGINALS OF ANY DOCUMENTS AND ENCLOSE WITH THIS APPLICATION. THESE CAN BE BROUGHT TO THE INTERVIEW (IF SELECTED)

WE WILL ALSO NEED TO SEE PROOF OF YOUR NATIONAL INSURANCE NUMBER AND ELIGIBILITY TO WORK WITHIN THE UK

Data Protection Statement

The personal information (data) collected on this form, and on the attachments, (which includes the collection of sensitive personal data) are collected for the purposes of recruitment, personnel administration (for new employees) and monitoring. Unless you direct otherwise (for example in a situation where you would like this Application kept on file for future vacancies) the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6 months. It is the policy of the Agency to protect, and keep secure, all personal data collected. All personal data is processed for the purposes of recruitment, and, in the case of successful Applicants, for the satisfactory administration of their employment, and for no other purpose.

Equality of Opportunity Statement

The Agency's Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.

1. Personal Details (Please complete this section in BLOCK letters)
TitleSurname:
Forenames:
Marital StatusMaiden Name
NationalityDate of birth
Country of BirthNI Number
Address

Next of Kin Details

2. Education and Qualifications - Start with the most recent
If more space is needed, please continue on a separate sheet.
3. Employment History

Present or most recent employment

Previous Employment

Start with your most recent previous employment and list in date order, going back to school leaving date.
4. Membership of Professional Bodies and Training
Name of Professional or technical associationDate of membershipStatus
5. Please list any other training courses you have attended:
Click "Add Training Course" to add more rows as needed.
DetailsDatesQualification
6. Region you are available to work in:
7. Skills and Experience

To enable us to match your previous experience and skills to a client's care needs, please indicate which of the following areas of care work you have experience of.

8. Personal Reference

References are normally taken up for candidates selected for interview. Give details of the names/addresses of two work-related Referees. One of the Referees should be your current employer, or if presently unemployed or self-employed, your last employer.

Employment Reference 1

Employment Reference 2

9. Health Records

All applicants are required to make a statement with regards to their physical and mental fitness.

Are you suffering, or have you ever suffered from any of the followingYesNo
a) Back or neck pain?
b) Rheumatic or arthritic conditions?
c) Hernia?
d) Upper limb disorder such as tenosynovitis, tendonitis or carpal tunnel syndrome?
e) Fits, fainting attacks, epilepsy?
f) Depression, anxiety or nervous illness?
g) Typhoid, paratyphoid, dysentery or food poisoning?
h) Tuberculosis or hepatitis?
i) Any illness or medical condition not specified above?
10. Criminal Convictions

Due to the nature of the work for which you are applying, this post is exempt from the provisions of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants are therefore required to disclose any "spent" or unspent convictions, cautions, reprimands, penalty notices and final warnings that they have received.

Have you any previous spent or unspent Criminal Convictions given by the Courts/Police? Yes No
Are you currently under investigation or do you have any Prosecutions pending by the Courts/Police? Yes No
Have you ever been cautioned or received a reprimand by the Courts/Police? Yes No
Have you ever received a Penalty Notice from the Police? Yes No
Have you ever received a final warning by the Courts/Police? Yes No
To your knowledge, are you named on any lists held by the Departments of Health or Education? Yes No
Have you ever been questioned by the Police regarding a criminal offence? Yes No

Note: To protect the confidentiality of this information, you may provide details on a separate sheet if preferred.

11. Rehabilitation of Offenders Act

As a general rule, no-one need answer questions about spent convictions. However this general rule does not apply to specified professions, employments and occupations. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to:

a) any employment or other work which is concerned with the provision of health services and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to persons in receipt of such services in the course of his normal duties, or

b) any employment or other work which is concerned with the provision of care services to vulnerable adults and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to vulnerable adults in receipt of such services in the course of his normal duties

One or both of the above apply to work with the Agency, and covers all occupations.

You are therefore requested to provide details of all convictions, including those which would otherwise be considered as "spent". All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected.

Records will be checked via the Criminal Records Bureau procedures

Note: To protect the confidentiality of this information, please detail convictions on a separate sheet of paper. Place it in a sealed envelope with your name clearly visible, and headed "Private and Confidential -- Criminal Convictions" and attach this to your completed Application Form.

12. Asylum and Immigration Act 1996

Under Section 8 of the Asylum and Immigration Act 1996 it is a criminal offence to employ a person aged 16 or over who is subject to immigration control unless:

  • That person has current and valid permission to be in the United Kingdom and that permission does not prevent him or her from taking the job in question; or
  • The person comes into a category specified by the Home Secretary where such employment is allowed

Any employment offered will be subject to the successful applicant producing appropriate evidence that the Asylum and Immigration Act is not being contravened.

13. Personal Declaration

I declare that to the best of my knowledge the above information, and that submitted in any accompanying documents, is correct, and

  • I give permission for any enquiries that need to be made to confirm such matters as qualifications, experience and dates of employment, and for the release by other people or organisations of such information as may be necessary for that purpose.
  • I give permission for the processing of the personal data contained in this form for employment purposes
  • I understand that any false or misleading information could result in my dismissal.

E-Signature for Personal Declaration

Optional: You can draw your signature below or type your name

OR draw your signature below:

Use mouse or touch to sign in the box above

Signature Preview:

Signature Preview
14. Working Time Regulations (1998)

I agree that I can be required to work for more than 48 hours on average per the duration of the contract made between the Client (and/or Zanta Healthcare Ltd) and myself because of the continuous nature of the services provided to the Client.

I understand that I can change my mind four weeks written notice to the Client (and/or House of Care Services) and I agree to provide a copy of that notice to House of Care Services for information.

E-Signature for Working Time Regulations

Optional: You can draw your signature below or type your name

OR draw your signature below:

Use mouse or touch to sign in the box above

Signature Preview:

Signature Preview
15. Supporting Statement

Please use this section to provide any further information which you think will support your application further. Please evidence using your previous skills, knowledge and experience how you meet the criteria detailed in the role profile. Include any skills of experiences that have been gained through paid employment, voluntary work, and community activities or through family experience.

Please use the space here and no more than TWO additional sheets.

16. Equal Opportunities

Zanta Healthcare Ltd is an Equal Opportunities Employer. The aim is to ensure that no job applicant receives less favourable treatment on the grounds of race, colour, creed, nationality, ethnic or national origin, religious belief, political opinion or affiliation, gender, marital status, sexual orientation or disability, or is disadvantaged by conditions or requirements which cannot be shown to be justifiable.

Our selection criteria and procedures are frequently reviewed to ensure that individuals are selected on the basis of their relevant merits and abilities. All employees are given equal opportunity and are encouraged to progress within the organisation. We are committed to an on-going programme of action to make this policy fully effective.

Please select a category and tick the box that is appropriate to you:

WhiteMixedAsian/Asian BritishBlack/Black BritishChinese/other ethnic group

Please ensure that the following documentation is enclosed when returning this form:

  • Copy of driving licence (where applicable)
  • Copy of car insurance (where applicable)
  • Recent passport size photograph

If you have any friends who may be interested in this type of work advise us of their name and address and we will be please to send those details.

Thank you very much for contacting Zanta Healthcare Ltd look forward to hearing from you.

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