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Senior Job Application Form

"*" indicates required fields

DD slash MM slash YYYY
Address:*

History

School, College, University:*
Date from mm/yyyy
Date to mm/yyyy
Name of secondary school, college or university
Main subjects taken
Qualifications/grades
 
Other Training:
Date (yyyy)
Specialised training undertook
 
Other Training Example - First aid
Other Qualifications and Skills:
Date (yyyy)
Specialised training undertook
 
Other Qualification Examples - Languages, keyboard skills, driving licenses
Work History:*
Date from mm/yyyy
Date to mm/yyyy
Name of employer
Nature of business
Position
Summary of main duties
Rate of pay (£)
Reason for leaving
 

Personal Statement

Please provide details of skills, knowledge, and achievements you feel may be relevant to the role.

Past Employment

Have you any holidays currently booked?*

Reference 1

Please use your most recent employer
The below information is my most recent employer:*
Company Address:*
Can we take up this reference before an offer of employment is made?*

Reference 2

A previous employer or personal reference
Company Address:*
Can we take up this reference before an offer of employment is made?*

The Disability Discrimination Act 1995 (DDA) protects disabled people. The DDA defines a person as disabled if they have a physical or mental impairment, which has a substantial and long term (ie has lasted or is expected to last at least 12 months) and adverse effect on the person's ability to carry out normal day-to-day activities. The list below contains an example of the types of impairment: ⦁ Physical impairment, such as difficulty using your arms or mobility issues which means using a wheelchair or crutches. ⦁ Sensory impairment, such as being blind/having a serious visual impairment or being deaf/having a serious hearing impairment. ⦁ Mental health conditions, such as depression or schizophrenia. ⦁ Learning disabilities such as dyslexia or cognitive impairment such as autism. ⦁ Long-standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy. ⦁ Other, such as disfigurement.

If you have answered yes, do you require any facilities or adjustments to assist you:
Do you require any facilities or adjustments to assist you to attend the interview:*
Do you require any facilities or adjustments to assist you if you are offered employment:*

Declaration

Declaration:*
I certify that all the information contained in this form and any attachments are true and accurate and correct to the best of my knowledge. I realise that false information or omissions may lead to dismissal, without notice.
Hazelwood Homecare Ltd is registered under the Data Protection Act to hold information about employees. The information provided on this form will be used as part of our selection process and will be retained for a period after the selection process has been completed.

In support of

Hazelwood Homecare in support of The Homecare Association
Hazelwood Homecare in support of Dementia Friends

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Hazelwood Homecare Ltd
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