Self Employed Mental Health
Resume:
Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 1
All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Application Form
To be completed in typed form or in your own handwriting in black ink Bold bordered sections are mandatory fields
Refer carefully to the job description and person specification. If the space provided is insufficient please continue on a separate sheet. Post Applied for:
Vacancy
Reference No:
Where did you first find this vacancy?
(If in publication, please state which
one. If from current employee of
Creative Support, please state name)
Company Website Jobcentre Guardian Charity Jobs
Reed Other (State) Preferred Client Group and Hours:
Mental Health Learning Disabilities Other
Older People No Preference Office
Full Time
Part Time
Have you a current in-date DBS
Certificate?
Yes No
Is it registered for the DBS
update service? (£13 per year
subscription)
Yes No
Have you previously applied for a post
with Creative Support?
Are you over 18 Years Old
Yes No (If Yes, please specify):
Yes No
Personal Details Title:
Forename(s) or other names
Surname
Address
Postcode:
Telephone
Home: Work:
Mobile:
Email Address
Car Driver: Yes No Car Owner: Yes No
Do you have any endorsements on your licence?
(if so please outline why)
Yes No
Are you a UK or EU/EEA national?
(If so you will need to provide proof of this at your interview)
Yes No
If you are not a UK or EU/EEA national can you provide proof of permission to work in the UK?
If you cannot provide proof of permission to work in the UK we cannot accept your application as you are unable to work legally in the UK.
If you can provide proof of permission to work please state the nature of your permission to work in the UK, any restrictions on the hours you are permitted to work and the expiry date of the permission.
Yes No
We will require sight of the documentation which
confirms that you are permitted to work in the UK at the interview stage. We may need to take a copy of the document and to carry out checks to authenticate it. Describe the type of permission to work in the UK: Hours permitted to work:
Expiry Date:
Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 2 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Employment History
Present or most recent employment (paid or unpaid) This includes any roles prior to moving to the UK (if applicable) Employer Name, Address
including Post Code and
Telephone Number
Date(s)
Employed
Position(s) Held and
Salary
Employed/Self Employed
Employed
Self Employed
Outline of Duties and Responsibilities:
Reason For Leaving
Please state reason for leaving and confirm current employment status: Number of Weeks Notice Required:
Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 3 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Previous Employment
Please list in chronological order with your most recent post listed first including temporary, casual and short term jobs
(Please give your full employment history since leaving school. If you require extra space please attach an additional sheet)
Employer Name, Address including
Post Code and Telephone Number
Date(s)
employed
Position(s) held and
salary
Reason for leaving
Outline of Duties and Responsibilities
Employer Name, Address including
Post Code and Telephone Number
Date(s)
employed
Position(s) held and
salary
Reason for leaving
Outline of Duties and Responsibilities
Employer Name, Address including
Post Code and Telephone Number
Date(s)
employed
Position(s) held and
salary
Reason for leaving
Outline of Duties and Responsibilities
Employer Name, Address including
Post Code and Telephone Number
Date(s)
employed
Position(s) held and
salary
Reason for leaving
Outline of Duties and Responsibilities
Gaps in Employment
Please give details of all periods when not in employment, giving dates and reasons
Dates from: To: Reason:
Dates from: To: Reason:
Dates from: To: Reason:
Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 4 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Have you ever been dismissed from a previous post or had an employment contract terminated for any reason including redundancy? If so please give details below: Have you been subject to disciplinary action in your current or any previous posts? (including being the subject of any disciplinary process not yet concluded to resignation) If yes, please give details: Voluntary Work Experience
Give details of any voluntary or unpaid experience including care of others Language Skills
List all languages spoken fluently and those in which you have a good working knowledge Please tell us why you are applying for
this post and why you want to work for
Creative Support
If in current employment, please explain why you are looking for a new post:
Do you have any restrictions in your
working hours or availability?
Please note our requirements in respect
of working hours as detailed within the
Job Description
Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 5 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 General Education Qualifications Achieved
School/College From To
Subject/courses studied, level and grade
(eg, GCSE, ‘A’ Level, GNVQ etc)
Further and Higher Education Qualifications Achieved College/University From To
Subject/courses studied, level and grade (eg, BA History 2:1)
Professional Training Qualifications Achieved
College/University
From
To
Subject/courses studied, level and grade (e.g., BA Social Work/DipSW 2:1)
Professional Membership of Registered Bodies Registration No/Renewal Date Name of Professional Body and
Level of Membership
Date
Nurses, please give PIN No.
Social Workers please give GSCC Registration No
NVQs and other work related qualifications Qualifications Achieved College/Training Provider From To
Awarding body, level and grade if applicable (eg,
Edexcel NVQ 4 Pass)
Other vocational and work related training undertaken List subjects, e.g., First Aid Duration (e.g., 1 day) Level (if appropriate) Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 6 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Additional Supporting Information
What experience have you gained in your current and previous jobs and general life experience, which you feel would be relevant to the job you are applying for?
The job description and person specification outline the values, skills, abilities, knowledge and personal qualities required for this post and the organisation. Continue on a separate sheet if necessary. If you wish to attach a CV or other information please do so.
Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 7 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 References
Please supply the names and addresses of two professional referees who have agreed to provide a reference. It is essential that one of your referees must be your current or most recent employer* and that your referee is/was your line manager and not a colleague, relative or friend. Both references cannot be from the same company. References will be verified to ensure authenticity. Failure to provide the above can result in your application being withdrawn.
*If previously self-employed, please provide two professional referees and detailed information regarding your self-employment
Current employer or
most recent employer
details
Company
(Business Addresses
Only)
Name
Position
Address
Post Code:
Tel
Fax
Can this reference be contacted prior to interview Yes / No Previous employer (if
not applicable an
academic referee)
Company
(Business Addresses
Only)
Name
Position
Address
Post Code:
Tel
Fax
Can this reference be contacted prior to interview Yes / No
* Unless indicated otherwise all referees will be contacted following your notification of success at individual Interview
DATA PROTECTION ACT
In accordance with the Act, you should be aware that the personal details submitted with this application form will be used only for selection and interview procedures; and for employment records if the application is successful. DECLARATION
I declare that, to the best of my knowledge and belief, all statements contained in this form are correct and I understand that should I conceal any material fact, I will, if engaged, be liable to the termination of my contract of service with such notice as may be appropriate.
Signature: Date: Have you ever been convicted of any criminal offence? YES NO Please note that all positions are subject to an enhanced DBS check. You will be asked to declare all criminal convictions in further details if an offer of employment is made.
Contact this candidate