Crossroads Care Rotherham
01709 360272
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Forms
Application Form
Application Form
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Vancancy Application Form
Which role are you applying for?
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Care Support Worker
Care Support Worker (bank staff)
Title
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Mr
Mrs
Miss
Ms
Dr
Forename
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Surname
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National Insurance
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Address line 1
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Address line 2
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Address line 3
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Postcode
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Telephone
Mobile
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Email
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Rehabilitation of Offenders Act 1974 and exception order 1975
Because of the nature of the work for which you are applying, you must provide information about any convictions. Our power to require this lies in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, which removes the normal operation of the Act in relation to specific occupations, including the provision of Home Care Services. In the event of being employed in connection with this application, any failure to disclose such convictions could result in dismissal or disciplinary action. Crossroads Care Rotherham follows a Code of Practice about the fair use of disclosure information, and a copy is available on request. If you do have any previous or outstanding convictions, details of the type of offence, date, sentence, fine etc. should be placed in a separate, sealed envelope which will subsequently be returned to you. It will only be opened if you are considered for the appointment. Such information will be completely confidential to the appointing panel. A criminal record will not necessarily be a bar to obtaining a position.
Do you have any criminal convictions, cautions, reprimands or final warnings?
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No
Yes
If yes, please provide additional information.
Do you have access to a vehicle?
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No
Yes
Do you hold a full driving licence?
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No
Yes
Education & Training
Please list your qualifications and the dates they were achieved.
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Professional Qualifications/Higher Education
Please list your qualifications and the dates they were achieved.
Previous Employment
Please start with your FIRST job and ensure that any gaps in employment history are explained.
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Present/Last Employer
Employer name
Employer address
Start date
End date
Job role
Salary
Period of notice, if applicable.
Reason for leaving
Primary responsibilities
Achievements
Employer Reference
Name of reference
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Contact number
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Address of reference
Further Information
Please tell us about yourself and why you would like to work for Crossroads Care Rotherham. What skills do you have to offer and why do you think these skills would support your application for the role.
Detail your successes in your previous roles
Declaration
I declare that the information on this application form is true and accurate, to the best of my knowledge. If untrue or inaccurate information is recorded, any employment contract may be invalidated and the employee subject to disciplinary action or dismissal.
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GDPR
Your details will be kept secure and we will never pass your details onto third parties. For full details, see our Privacy Policy below.
Please tick to consent to your data being stored in line with the guidelines set out in our Privacy Policy
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EQUALITY & DIVERSITY MONITORING
Crossroads Care Rotherham strives to operate a policy of equality and diversity and not discriminate against any person. The information you provide will be treated in the strictest confidence and is for monitoring purposes only and in no way forms any part of the selection process.
Where did you see the post advertised?
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Community Hub
Crossroads Website
Facebook
Indeed
Jobsite
Leaflet
Newspaper
VAR
Word of Mouth
How would you describe your cultural or ethnic origin?
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Asian or Asian British - Bangladesh
Asian or Asian British – Indian
Asian or Asian British – Pakistani
Asian or Asian British – Any Other Asian Background
Black or Black British – African
Black or Black British – Caribbean
Black or Black British – Any Other Black Background
Chinese
Mixed – White and Asian
Mixed – White and Black African
Mixed – White and Black Caribbean
Mixed – Any Other Mixed Background
White – British
White – Irish
White – Any Other White Background
Any Other
I do not wish to disclose
Gender
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Male
Female
Gender Neutral
Age Group
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0-15
16-24
25-64
65-79
80-99
100+
Sexual Orientation
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Bisexual
Gay
Heterosexual
Lesbian
I Do Not Wish to Disclose
Marital status
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Common Law
Divorced
Married/Civil Partnership
Single
Widowed
I do not wish to disclose
Religious belief
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Atheism
Buddhism
Christianity
Hinduism
Islam
Judaism
Jainism
Sikhism
Other
I Do No Wish to Disclose
Do you consider yourself to be disabled?
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No
Yes