Application Form Generic application form for Quality Lifestyle Ltd vacancies Position Type*Please state which position you are applying for Homeland Residential Home The Lodge Residential Home Homecare / Domiciliary Care Job Type*Please state what type of employment you are seeking Full Time Part Time Days Nights Personal DetailsName* First Last TitleFor example Mr, Mrs, Ms, DrEmail*Please provide your email address so we can send you a confirmation that your application has been submitted successfully Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Telephone Number*Mobile Telephone NumberNational Insurance Number*Driving Licence*Do you hold a current, full driving licence Yes No How long have you held your driving licence in the UK?0 - 2 years3 - 5 years6 - 10 years10 years +Do you have a car available? Yes No Details of any penalty pointsPlease state when and what they were forAre you Registered Disabled?* No Yes Disability Registration NumberPlease provide your registration number if you are registered disabledCurrent EmploymentName and Address of Current EmployerPlease provide the full name and address of your current employerPost HeldWhat is your post with your current employerContracted Hours Per WeekWhat are your current contracted hours with your current employerSalarywhat is your current salary or hourly ratePlace of WorkWhere is your current place of workWhy do you wish to leave your present employer?Do you have a legal right to work in the UK?*If yes, it may be necessary to ask for documentary evidence of this Yes No Employment and Education HistoryPrevious Employment - you MUST complete all of the information asked for below:*Please record your complete employment history and detail any gaps. You MUST include: the Dates/Period of Employment; the Post Held and Description of Duties and your Reason for LeavingHistory of Education - you MUST complete all of the information asked for below:*Please record education history here. You should include: the Name of School / College / University or Training Provider; the Degree / Diploma or Qualification Passed and Grade Obtained and the Date.Qualifications currently being studied forPlease provide information here of any qualifications or courses you are currently studying and provide the completion datesTraining CoursesPlease provide details of any additional training courses you have attended and include certificates obtained and dates Supplementary Information*Please use this space to provide any additional information you would like to support your application. This might include further details on your present or previous employment and the skills you can bring to this post. ReferencesReference 1*Please provide the name, address and telephone number of your current employer or last employer if you are not currently employedMay we apply for Reference 1 now? Yes No Reference 2*Please provide the name, address and telephone number of a second referee May we apply for Reference 2 now? Yes No If you do not wish your employer to be approached unless you are shortlisted to attend for interview please check the box. Please do not contact my employer Disclosure and BarringRehabilitation of Offenders Act 1974: Have you received a court conviction, reprimand, warning or caution?*This post is exempt from this Act. You are not entitled to withhold details of any convictions no matter when they occurred. Failure to disclose this information could result in your contract being terminated. NoYesDetails of ConvictionsIf you answered yes to the above question, please provide details hereIf your application is successful, a Disclosure and Barring Service (DBS) Check will be undertaken DeclarationI declare that the information given by me on this form is, to the best of my knowledge accurate and true. I am prepared to undertake a health screening appointment if necessary and there are no known health reasons which may affect my ability to undertake the duties of the post. I confirm that this application form has been completed by me.Signature of Applicant*When submitted electronically we will accept a typed-in name as your signatureDate of Application*Captcha
