Independent Community Care Management Limited

2 Swallow Court, Kettering Parkway West, Kettering Venture Park, KETTERING, Northamptonshire, NN15 6XX. Tel: 01536 525220 Fax: 01536 513113. www.iccmcares.co.uk

OFFICE USE ONLY: Date Received: Interview Date: 2nd Interview Date: Client ID: Offer: Yes/No File Passed:

Confidential Application Form

Name: Job Reference:

Contacting You:
Title: Forename(s): Address: Surname:

Postcode: Contact number(s): Email:

Further Details: YES NO

NI Number: Are you eligible to live and work in the UK? (in accordance with the Immigration, Asylum & Nationality Act 2006): Please provide details which will confirm this status: Are you a car owner? Are you able to access a car for work purposes? Do you have a full UK drivers licence? *Are you related to anyone who currently works for ICCM? *Are you related to a client under the care of ICCM? *If you have answered YES to either of the above provide details:

YES YES YES YES YES

NO NO NO NO NO

Availability/Preferences:
Which locations are you prepared to work:

Your availability please be aware that limited availability will reduce the number of vacancies we screen you for. I am fully flexible. Any time (Day or Night) Any day. I am fully flexible (Day or Night shifts) on: MON TUES WEDS

YES THURS

FRI

NO SAT

SUN

Other Please indicate your BEST availability in detail below:

Please indicate your agreement for your application details to be shared with our clients for their consideration. (Includes the full application form).

YES

NO

Health/Medical
Do you consider yourself disabled as defined under the Disability Discrimination Act 1995? Do you have any medical conditions affecting your ability to carry out this role? Are there any reasonable adjustments required in order for you to carry out your role or to attend your interview? If you have answered YES to any of the above please provide details below:

YES YES YES

NO NO NO

Criminal Convictions: The post you are applying for is excluded from the Rehabilitation of Offenders Act 1974. You must disclose details of all criminal convictions/warnings or reprimands, spent or not, imposed as a juvenile or adult. We carry out checks on the information you provide, and should it be discovered that you have provided false information, it will lead to any job offer being withdrawn - or your dismissal from our employment.
Have you ever been convicted of any Criminal Offence, or received a caution, reprimand or warning in the UK or any other country, as a juvenile or adult? Are you, or have you ever been the subject of a police investigation or proceedings which may/may not have resulted in a conviction, caution, reprimand or warning?

YES YES

NO NO

If you have answered YES to any of the above please give details below:

Education/Qualifications:
Please detail Schools attended and academic qualifications:

Please detail any Further/Higher Education (College/University) Qualifications including dates attained: Detail any Vocational qualifications including dates attained: Professional Qualifications/Registrations: (include registering body and nursing PIN numbers where appropriate):

Employment History. This must be a complete record of your working life, including a declaration of any gaps in employment history and what you were doing at this time, continue on a separate sheet if required. Current Employer Name and Address: Position Held: Dates Duties/Responsibilities: From/To: Reason for Leaving:

Previous Employer Name and Address:

Position Held:

Dates Duties/Responsibilities: From/To:

Reason for Leaving:

Previous Employer Name and Address:

Position Held:

Dates Duties/Responsibilities: From/To:

Reason for Leaving:

Previous Employer Name and Address:

Position Held:

Dates Duties/Responsibilities: From/To:

Reason for Leaving:

Supporting Information: Please tell us why you feel you are suitable for the role you are applying for, and about any relevant experience, skills, knowledge and competencies you have.

References (We require THREE references to support your application): Please give contact details of three referees below. Included where possible, should be your current and previous employer and a person who is prepared to give a character statement. We may obtain references from any of your past employers detailed in your application as necessary. 1. Employer Reference (existing if applicable): Name: Position: Company Name: Street Name: Town/City: County: Post Code: Telephone Fax Number: Number: Email address (if known): 2. Employer Reference: Name: Position: Company Name: Street Name: Town/City: County: Post Code: Telephone Fax Number:

Number: Email address (if known): 3. Character Reference: Name: What capacity known: House Name/Number: Street Name: Town/City: County: Telephone Number: Email address (if known):
Declaration and Signature:

Post Code: Fax Number:

I confirm that the above information is a true record. I consent to the Company checking any information provided on this form, and I understand that giving false information may lead to any job offer being withdrawn, or to formal action up to and including termination of my employment.

Signed: Date:

EQUAL OPPORTUNITY MONITORING - PRIVATE AND CONFIDENTIAL

Job Ref No.:

Position applied for: We are an equal opportunity employer. The aim of our policy is to ensure that no job applicant or employee receives less favourable treatment on the grounds of race, colour, ethnic or national origin, religious belief, sex, marital status, sexual orientation, gender reassignment, age 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, promoted and treated 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 ongoing programme of action to make this policy fully effective. To ensure that this policy is fully and fairly implemented and monitored, and for no other reason, would you please provide the following information:Date of Birth: _____________________ Nationality: __________________________

I would describe my ethnic group and sex as:- (please tick one box for your ethnic group and one box for your sex) If you are completing your application online please confirm your ethnic group here;_____ ____________ White y English Scottish Welsh Irish

Any other White background, please specify .... Mixed White and Black Caribbean White and Black African

White and Asian

Any other Mixed background, please specify ....

Asian, Asian British, Asian English, Asian Scottish or Asian Welsh Indian Pakistani Bangladeshi

Any other Asian background, please specify .... Black, Black British, Black English, Black Scottish or Black Welsh Caribbean African

Any other Black background, please specify .... Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh or other Ethnic Group Chinese Sex Male Female Any other background, please specify ......

Please indicate where you heard about this vacancy ICCM Website Job Centre Press: please state publication name____________________________ Word of Mouth Other Website: please state website name____________________________ Other: please give details____________________________ Name (in Capitals): . Signed: .. Date:

Please email your completed application form to martina@iccmcares.co.uk