Prospect-Tree Health Care
Suite 2, The Boot Factory
22 Cleveland Road
Wolverhampton
WV2 1BH
01902 717856

                                                                                       
                                                                                                          Prospect Tree Health Care

Please read the following before completing your application form.

PLEASE NOTE: YOU ARE PAID FOR THE DURATION OF EACH VISIT. CURRENTLY WE DO NOT PAY FOR TRAVEL IN BETWEEN SERVICE USERS HOMES. HOWEVER, WE DO ENDEVOUR TO KEEP YOU IN THE SAME AREA.

Page 1 - Personal details
If your application is successful and you intend to work for any other company please give as many details as possible in the relevant section.
Include the number of hours you would like to achieve each week and also any holidays you have booked. Prospect Tree will honour holidays that are detailed on this application. However, if details are not provided, we cannot guarantee this will be the case. Annual leave requests are authorised based on a first come, first serve basis and only a certain amount of care staff are permitted to take leave at the same time. Unfortunately, annual leave will not be permitted from 10th Dec through to 10th January.

Page 2 - Availability to work
Please provide details of the days/hours you are available to work. Prospect-Tree offers domiciliary care services from 06:00 through till 22:00, 7 days per week, 365 days per year (including Christmas day). If your application is successful, you will be offered a position based on your availability to work. Therefore, please give careful consideration to this section. You will need to consider any other commitments you have when completing this section. 
Your rota will be issued each Friday, based on your availability. This means that unless you have booked annual leave, you are highly likely to be working the same days each week. 
If your availability changes before commencing with Prospect Tree, we may withdraw the job offer. If availability changes during your employment, you are entitled to request a change of hours in writing. This will be agreed at the Care Managers discretion, based on business needs.
If you require further information on this section please speak to a member of staff before completing.

Page 3 – Education and Qualifications
You will be asked to provide evidence/certificates for all training and qualifications. 

Page 4 – Employment history
If you have any gaps in employment, please attach a separate sheet explaining the reason for this.

Page 5 – References
We will require three references in total, two of these must be from your previous employer(s). One can be a character reference.

Page 6 – About you
Please give details of why you would like to join our team at Prospect Tree and also any previous experience you have relevant to the position you are applying for.

Page 8 – DBS
Read through the information provided on page 7 before completing this section. Ensure all information provided is accurate and correct. Prospect Tree will cover the costs of your DBS. However, if you terminate your contract of employment within 12 months of commencement date, £49.50 will deducted from your salary. We will require I.D such as; driving licence, birth certificate, marriage certificate, passport and utility bills. These must be presented when completing the application.
If you require any further information please contact us during office hour’s mon-fri 9am to 4pm and speak to a member of our team.

PROSPECT-TREE HEALTH CARE

PRIVATE AND CONFIDENTIAL

APPLICATION FORM – PART 1

PERSONAL DETAILS

Position Applied for:		
Title:	Surname:		
Forename(s):	Preferred Name:		
Address:		
	
Post Code:		
Home tel. no:	Mobile tel. no.:		
Work tel. no:	E-mail address:		
Date of Birth:	National Insurance no.:		
Do you own a car?	Y /  N	Current Driving License?	Y  / N	
Do you have any endorsements?	Y /  N	If yes, provide details:		
Are you entitled to work in the UK?	Y  / N	Do you require a work permit?	Y  / N	
Please notify us of any additional employment you would continue with should you be successful in your application with Prospect-Tree Health Care in the space below:	
Please notify us of your hours/days of availability to work, and any holidays you may have booked:	

AVAILABILITY TO WORK
Please pay particular attention to this section - if your application is successful, you will be offered a position based on your availability to work.

Day	A.M	P.M	

Monday Tuesday Wednesday Thursday Friday Saturday Sunday	
From	To

From	To

From	To

From	To

From	To

From	To

From	To	
From	To

From	To

From	To

From	To

From	To

From	To

From	To	

AVAILABILITY DECLARATION	

Should my application be successful, I hereby agree to be available for work with Prospect-Tree Health Care within the above stated times. I am aware that my rota will be issued based upon the above hours, and that this will be on a permanent basis. A position has been offered to you based on your hours of availability (as stated above). I understand that if my availability should change for
any reason, then it is my responsibility to contact the office as soon as possible and give one calendar month (excluding emergencies) notice for these changes to take effect.

Name:  …………………………………………………..

Signed: ………………………………………………….. Date: ………………………………………..	

TO BE COMPLETED BY THE APPLICANT ONLY

EDUCATION & QUALIFICATIONS

School/College/University	Attended from	until	Qualifications gained/grade attained	

Additional Courses/Training	Date achieved	Qualifications gained/grade attained	

FULL EMPLOYMENT HISTORY
•	Please complete in full, using a separate sheet if necessary, starting with your most recent employment.
•	For any periods spent working for two or more employers simultaneously you must include both/all employers.
•	You must give reasons for any gaps in employment.
•	If you are currently employed, please indicate this and provide details of your required notice period.
•	If you previously worked with vulnerable adults or children, you must provide your reason for leaving.

Name and Address of Employer	Dates Employed, Job Title and Duties	Salary on Leaving	Reason for Leaving	

				

REFERENCES

Please provide details of at least two referees, preferably three, who can provide information relating to your competency in a caring role, one of whom must be your present or most recent employer. If you are a student, please give an academic referee. If you are applying for a post which requires unsupervised access to vulnerable adults, we reserve the right to approach any past employer for a reference.

Name:		
Company:	Position:		
Address:		
Post Code:		
Tel. no:	                                      	
EMAIL ADDRESS		

Name:		
Company:	Position:		
Address:		
Post Code:		
Tel. no:		
EMAIL ADDRESS		

Name:		
Company:	Position:		
Address:		
Post Code:		
Tel. no:		
EMAIL ADDRESS		

ABOUT YOU

Please detail below your reasons for this application. You should consider what attracted you to want to work for Prospect-Tree Health Care, your main achievements to date,
and your relevant strengths, knowledge, skills and experience that you would bring to us.	
	
Please tell us about yourself. You should include your leisure interests, any sports or hobbies, any other pastimes etc.	

Please carefully read the following information regarding the Rehabilitation of Offenders Act 1974, and the Policy Statement on the Recruitment of Ex Offenders before completing the following declaration.

Certain posts, particularly those that involve working with children or other vulnerable groups, will be subject to a criminal record check from the Disclosure and Barring Service before the appointment is confirmed. This will include details of cautions, reprimands, final warnings and convictions, including „spent convictions‟ under the terms of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986. Any disclosure will be required only if you are selected as the most suitable applicant for the post. Prospect-Tree Health Care also reserves
the right to contact previous employers of the successful candidate prior to appointment to confirm employment history.

1.	As an organisation using the Disclosure and Barring Service (DBS) to assist in assessing applicants suitability for positions of trust, the company complies fully with the DBS Code of Practice (a copy of which is available on request) and undertakes to treat all applicants for all posts fairly. The company will not discriminate unfairly against any subject of a disclosure on the basis of a conviction or other information revealed.

2.	We actively promote equality of opportunity for all and we select all candidates for interview on the basis of their talent, skills, qualifications and experience. We welcome applications from a wide range of candidates, including those with criminal records.

3.	Disclosure forms part of our recruitment process. We encourage all applicants called for interview to provide details of their criminal record at an early stage in the application process.

4.	Unless the nature of the position allows the company to ask questions about a candidates entire criminal record we only ask about “unspent” convictions as defined in the Rehabilitation of Offenders legislation.

5.	We ensure that all those in the company who are involved in the recruitment process have been suitably trained to identify and assess the relevance and circumstances of offences. We also ensure that they have received appropriate guidance and training in the relevant legislation relating to the employment of ex-offenders.

6.	At interview, or in a separate discussion, we ensure that an open and measured discussion takes place on the subject of any offences or other matter that may be relevant to the position. Failure to reveal information that is relevant to the position sought could lead to withdrawal of an offer or termination of employment.

7.	We undertake to discuss any matter revealed in a disclosure with the person seeking the position before withdrawing a conditional offer or terminating employment.

8.	Having a criminal record will not necessarily bar an applicant from working for us. This will depend on the nature of the position and the circumstances and background of the offences.
1.	
Cautions, Rehabilitation and Criminal Records	
Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974, by virtue of the Exceptions Order 1975 as amended by the Exceptions (Amendment) Order 1986, which means that convictions that are spent under the terms of the Rehabilitation of Offenders Act 1974 must be disclosed, and will be taken into account in deciding whether to make an appointment. Any information will be completely confidential and will be considered only in relation to this application.

In addition you are required to submit to an DBS enhanced disclosure check. Any disclosure made by the DBS will remain strictly confidential.

Have you ever been convicted in a Court of Law and/or cautioned in respect of any offence?

YES / NO	(delete as required) If YES, please give details:	

Special Requirements	
Because of the nature of the work of this company involves the care of vulnerable adults, employment is dependent on the following:

1)	Your written consent to obtaining an enhanced disclosure certificate from the DBS and Barring Scheme.

2)	Such disclosures being acceptable to us.

3)	Proof of identity – birth or marriage certificate (where appropriate) and passport (if available).

4)	Two satisfactory written references.

5)	You supplying 3 recent passport-sized photographs of yourself for your ID care/retention in your records.	

Applicant Signature:	Date:

EQUAL OPPORTUNITIES MONITORING

Please complete the following information. This information is collected anonymously and is used by Prospect-Tree Health Care to monitor the effectiveness of our Equal
Opportunities Policy.

White	
British   [   ]	Irish   [   ]	Other   [   ]   Please state:	

Mixed	
White & Black Caribbean  [  ]	White & Black African   [  ]	White & Asian [   ]	Other   [   ]   Please state:	

Asian or Asian British	
Indian   [   ]	Pakistani   [  ]	Bangladeshi   [  ]	Other   [   ]   Please state:	

Black or Black British	
Caribbean   [  ]	African   [  ]	Other   [   ]   Please state:	

Chinese or other Ethnic Group	
Chinese   [   ]	Other   [   ]   Please state:	
	
Gender	
Male   [  ]	Female   [  ]	
Age	
16-20   [  ]	21-30   [  ]	31-40	[   ]	41-50   [  ]	
51-60   [  ]	61-64   [  ]	Over 65   [  ]	

PLEASE STATE LANGUAGES THAT YOU ARE ABLE TO SPEAK TO ASSIST US WITH PLACING YOU WITH SAME LANGUAGE SPEAKING CLIENTS.
LANGUAGES
SPOKEN	..................................................................................................................................
..................................................................................................................................
..................................................................................................................................

DECLARATION (Please read this carefully before signing this application)	

1.	“I confirm that all of the above information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.”

2.	Should Prospect-Tree Health Care require further information and wish to contact
your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor.

“I agree that Prospect-Tree Health Care reserves the right to require me to undergo a
medical examination. In addition, I agree that this information will be retained in my personnel file during employment and for up to six years thereafter and understand that information will be processed in accordance with the Data Protection Act.”

3.	“I agree that should I be successful in this application, I will apply to for a DBS an enhanced disclosure. I understand that should I fail to do so, or should the disclosure not be to the satisfaction of Prospect-Tree Health Care, any offer of employment may be withdrawn
or my employment terminated.”

Name:  …………………………………………………..

Signed: ………………………………………………….. Date: ………………………………………..	

Please return your completed Application Pack via post or in person to:
 Prospect-Tree Health Care
Suite 2, The Boot Factory
22 Cleveland Road
Wolverhampton
WV2 1BH
01902 717856

Good luck with your application