Application – Courtfield Health Care

Further Education
Where applicable, please include details of examinations which have been or are about to be taken but results of which are not yet available.
College/University Qualification Grade/Class (if applicable) Date obtained
Voluntary Eperience
Please detail any relevant voluntary experience that you have
Professional Qualifications
Awarding Body/Institution Qualification Grade/Class (if applicable) Date obtained

Employment History
Please provide details of all your employment starting with the most recent / current position, and any gaps for the last 10 years. College leavers must provide details of vacation employment.
Employer/Organisation Dates From-To Position/Grade Salary/Hourly rate Reasons for leaving Details of duties & responsibilities

Please provide as much detail as possible
Other Information
Please use the space above to give any other information you consider to be relevant, including reasons why you consider yourself a suitable candidate for this position.

References
Please supply the names and addresses of at least two people (not relatives) whom we may contact for references. One of these should be from your most recent employer and be from someone of a senior capacity.
Current Employer Name Position Address Phone Email
Previous Employer Name Position Address Phone Email
Discliplinary & Criminal Issues
Under the rehabilitation of Offenders Act 1974, certain previous convictions can be regarded as “spent” under certain circumstances, but this does not apply to persons seeking employment in Registered Care Homes. The information will be treated in confidence and only taken into account where, in the reasonable opinion of Courtfield Healthcare Ltd, the offence is relevant to the post for which you are applying. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment if the offence later comes to light.
Have you ever been convicted of any criminal offence?
- Yes
- No
Details of the offence
I hereby give consent for you to liaise with other agencies for example; police, social services, probation service,
- Yes
- No
Do you have a recent CRB check?
- Yes
- No

Declaration & Confidentiality Agreement
*
- I declare that the details which I have given are true.
*
- I understand that providing any misleading or false information to support my application will disqualify me from registration. I hereby declare that I have understood and complied with the requirements laid down in the previous paragraph and I agree that the information given on this form may be used for registered purposes under the Data Protection Act 1984.
Working Time Regulations
- I do agree that I may work for longer than the average 48 hours per week. If I change my mind I will give my employer and/or agency not less than one weeks notice in writing to end this agreement.
You are not required to work for more than an average of 48 hours per week. Only sign the above statement if you wish to be able to work for more than 48 hours per week.

Personal Details