Care Worker Application Form

(CQC Safer Recruitment Compliant)

Application Information

Position Applied For:

Date of Application:

1. Personal Details

Full Name:

Previous Name(s) (if applicable):

Current Address:

Postcode:

Telephone Number:

Email Address:

Date of Birth:

National Insurance Number:

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

Yes

2. Identity Verification

Please provide copies of:

Passport / Photo ID
Proof of Address (dated within 3 months)

Passport / Photo ID:

Proof of Address:

3. Employment History (Full History Required)

Please provide full employment history including unpaid work. Explain any gaps.

Employer	Job Title	From	To	Reason for Leaving

Explain any gaps in employment:

Additional information:

4. Qualifications & Training

Please list relevant qualifications (e.g. NVQ/QCF Level 2 or 3 in Health & Social Care):

Attach CV/Resume:

Attach Qualification Documents: You can upload multiple files (PDF, JPG, PNG)

Training Completed: Tick completed

Safeguarding Adults

Safeguarding Children (if applicable)

Manual Handling

Basic Life Support / First Aid

Infection Prevention & Control

Health & Safety

Fire Safety

Medication Awareness

5. DBS & Criminal Record Declaration

Do you hold a current Enhanced DBS?

Yes

DBS Certificate Number:

Issue Date:

Is your DBS registered with the Update Service?

Yes

Please disclose any convictions, cautions, reprimands, warnings, ongoing investigations or disciplinary proceedings (including spent convictions under the Exceptions Order):

6. Suitability Declaration (Safeguarding)

Have you ever been barred from working with vulnerable adults or children?

Yes

Have you had registration with a professional body refused, suspended or removed?

Yes

Have you been subject to safeguarding investigations?

Yes

7. Health Declaration

Do you have any physical or mental health condition that may affect your ability to carry out care duties safely?

Yes

If yes, please provide details:

8. Driving (If Role Requires)

Do you hold a valid UK driving licence?

Yes

Do you have access to a vehicle for work purposes?

Yes

9. References

Please provide two references (one must be your most recent employer, covering at least the last 3 years):

Reference 1 - Full Name:

Position:

Company/Organization:

Relationship to you:

Email:

Telephone:

Reference 2 - Full Name:

Position:

Company/Organization:

Relationship to you:

Email:

Telephone:

10. Supporting Statement

Please explain why you are applying for this role, your experience supporting vulnerable adults, and how you promote dignity, respect and safeguarding:

11. Declaration

I confirm that the information provided in this application is true and complete. I understand that providing false information may result in withdrawal of offer or dismissal. I consent to Enhanced DBS, Right to Work and reference checks.

All information you provide is not shared with any 3rd parties unless consented in compliance with GDPR statutes.

I agree to the above declaration *

Signed:

Print Name:

Date:

Thank you for submitting your application! We will review it and contact you soon.

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