Job Application — CLIA Care

CLIACare Job Application

Thank you for applying for a role with CLIA Care. Please fill out the job application below, with as much detail as possible. We will be in touch shortly.

Job Information

Post Applying for

Personal Details

Name

First Name

Last Name

NI Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Additional Information

Do you have the legal right to work in the UK?

If 'Yes' you have the legal right to work in the UK, but there are conditions attached, please specify (eg, start/finish dates, WRS etc)

Do you possess a valid driving license for the UK?

Criminal Record Declaration

The nature of the work you are applying for is exempt from the provisions of the Rehabilitation of Offenders Act 1974. If you are applying for a post involving access to persons in receipt of care services, your offer of employment will be subject to a satisfactory enhanced Disclosure and Barring check. It is therefore a requirement that all previous convictions are declared, even those which would otherwise be regarded as ‘spent’. (Any such information will be treated confidentially). Please read the above carefully and then answer the following questions:

Have you ever been convicted of a criminal offence?

Have you ever received any official cautions, reprimands or warnings?

To your knowledge, are you currently the subject of any criminal proceedings or any police investigation?

If you have answered yes to any of the 3 above questions, please provide the details (including driving offences)

Education, Training, Qualifications and Current Learning

Secondary Education Location

Secondary Education Qualifications:

Further/Higher Education:

Qualifications/Grades obtained:

Any other relevant training, professional qualifications or work related skills (including dates)

Any details of membership to professional bodies (please provide details including any offices held)

Employment History

Current/Most Recent Employer Name

Start Date

YYYY

End Date

YYYY

Job Title

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone Number

Country

(###)

###

####

Reason for Leaving

Brief description of duties and responsbilities

Full employment history

Please include job title, start dates, end dates, employers name and address, your duties/responsibilities and your reason for leaving.

Relevant Experience

Please use this section to state how your skills, experience and training would enable you to meet the requirements of the role for which you are applying.

Any relevant experience you have

References

Please provide the names and contact details of referees: the first referee must be your present or most recent employer, if there is less than two years between both of these then please provide a further reference. We will not contact any referee without your permission or until an offer of employment has been accepted. Also, if you have previously been employed in a position which involved working with vulnerable adults or children for more than three months then one of the references you provide must be from this agency/employer. (In accordance with the Health and Social Care Act 2008). Personal references such as relatives, friends, neighbours etc ARE NOT acceptable as referees

Current/Last Employer Name

Reference 1 Name

First Name

Last Name

Reference 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference 1 Phone Number

Country

(###)

###

####

Reference 1 Email Address

Reference 1 Relation to you (eg Manager)

Can reference be contacted prior to interview?

Previous Employer Name

Reference 2 Name

First Name

Last Name

Reference 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference 2 Phone Number

Country

(###)

###

####

Reference 2 Email Address

Reference 2 Relation to you (eg Manager)

Can reference 2 be contacted prior to interview?

Application Declaration

1. The information in this form is true and complete. I agree that any deliberate omissions, falsification or misrepresentation on this form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This equally applies to any medical questionnaires I may complete. 2. I confirm that I have not been subject to any cautions or convictions (other than those given above), investigation, disciplinary action, or enquiry into adult/child protection matters or inappropriate behaviour, and that the information I have given in the Criminal Record declaration section is to the best of my knowledge correct.

Signed (Your name)

We are CQC accredited to provide regulated care.