Polus Care New Starter Forenames * First Name Last Name Email * Date of birth * MM DD YYYY Gender Proposed Job Title Mobile Phone * Country (###) ### #### Telephone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country National Insurance Number * Please answer all of the following questions Have you ever had or suffer from the following: Dermatitis or skin trouble * Please select Yes or No Yes No Allergies including drugs, food or other substances? * Please select Yes or No Yes No Asthmas, hay fever, bronchitis, tonsillitis, sinusitis * Please select Yes or No Yes No Tuberculosis? * Please select Yes or No Yes No Heart or circulatory trouble? * Please select Yes or No Yes No Raised blood pressure? * Please select Yes or No Yes No Blackouts, epilepsy, fainting attacks or giddiness? * Please select Yes or No Yes No Nervous, mental disorders or 'nerves'? * Please select Yes or No Yes No Have you any disability or are you registered disabled? * Please select Yes or No Yes No Pain or injury to back? * Please select Yes or No Yes No Do you wear a hearing aid? * Please select Yes or No Yes No Any other medical condition or illness involving time off work? * Please select Yes or No Yes No Any other medical condition or illness involving time off work? * Please select Yes or No Yes No If you have answered 'Yes' to any of the above please provide further details below The following section is in relation to your Next of Kin Please have your 'Next of Kin' details to hand Employee’s Name * First Name Last Name Contact Person (in emergency) * Please enter Full name, contact number, and email address Relationship to Yourself * Husband Wife Partner Family Relative Other Bank Details I authorise you to pay my Monthly Salary/Wages directly into my bank / building society account. These details shall remain in force until cancelled by me in writing. * Agree Bank Name * Account Name * Account Number * Bank Sort Code * Please enter in this format 000000 Bank Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employee Statement Statement A Do not choose this statement if you’re in receipt of a State, Works or Private Pension. Choose this statement if the following applies. This is my first job since 6 April and since the 6 April I’ve not received payments from any of the following: 1. Jobseeker’s Allowance 2. Employment and Support Allowance 3. Incapacity Benefits Statement B Do not choose this statement if you’re in receipt of a State, Works or Private Pension. Choose this statement if the following applies. Since 6 April I have had another job but I do not have a P45. And/or since the 6 April I have received payments from any of the following 1. Jobseeker’s Allowance 2. Employment and Support Allowance 3. Incapacity Benefits Statement C Choose this statement if 1. you have another job and/or 2. you’re in receipt of a State, Works or Private Pension Which statement from the above applies to you? * Statement A Statement B Statement C Declaration I confirm that the information I’ve given on this form is correct I confirm I have provided that correct information Name First Name Last Name Employment References Please provide us with details of your 2 most recent employers, who we can contact to obtain references for you. References must be from somewhere you have previously worked-not a personal reference. We will only seek personal references if unable to obtain any from an employer. One reference must be your most recent Social Care employer(If you have previously worked in this sector) Reference 1 Please the nature of this employment (for example Social Care or Nursing) Name of the person who will provide the reference * First Name Last Name Job Title * On Behalf of Company: * Company Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * Country (###) ### #### Reference 2 Please the nature of this employment (for example Social Care or Nursing) Name of the person who will provide the reference * First Name Last Name Job Title * On Behalf of Company: * Company Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * Country (###) ### #### I give permission to Polus Care to obtain a reference from my named referees if I am offered employment with Polus Care. * Agree Criminal Convictions Due to the nature of the services that we offer to the people we support, it is important that we make safe recruitment decisions to protect vulnerable adults. We are open to employing people with past criminal convictions but because of the nature of our work with vulnerable adults (and/or children) most of our vacancies are exempt from the Rehabilitation of Offenders Act and there are some offences that we are unlikely to be able to accommodate. However, we do employ a number of people with a criminal record and having a criminal conviction will not automatically prevent you from being employed by us. We will discuss any disclosure with you before a final decision to employ you is made and we will conduct a risk assessment, based on the nature of the conviction and the role. If the conviction is unsuitable for the role you have been offered, the offer of employment will be withdrawn. Failure to disclose a conviction/caution, which subsequently comes to our attention, will be viewed very seriously and may result in the withdrawal of an offer of employment or your dismissal. Affinity Trust complies with the DBS Code of Practice for Registered Bodies and other recipients of Disclosure Information - a copy of the Code of Practice will be made available to any applicant upon request. Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as amended in 2013? * * Yes No If yes please provide details: Are there any pending prosecutions against you? * Yes No If yes please provide details: Additional Information Do you have any training or qualifications relevant to this role? * Yes No Are there any specific activities or tasks you would not be able or willing to support a person doing? * Do you have a full UK driving licence? * Yes No Thank you, your inormatio has been submitted.
