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1. Chipet Care and Sevices Ltd - Candidates Registration Form

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The information you supply on this form will be treated in confidence.

SECTION 1 : Personal Details

Post Applied For:*

Title:*

Mr, Mrs, Miss, Ms, Other

Name*

First Last

Have you ever been known by any other names:*

Yes

If Yes, enter names

Home Telephone Number:

Mobile Telephone Number:*

Email*

Sex:*

Date of Birth:*

Day

Month

Year

Are you aged 18 years or over:*

Yes

National Insurance Number (NI):*

Are you eligible to work in the UK?*

Yes

Nationality:*

Country

Right To Work (RTW) in the UK – Acceptable proof:*

British Passport

EU Passport / EU ID Card with proof of settlement

NON-UK & EU Passports should be accompanied with a BRP Card

Upload proof of Right to Work in the UK*

Max. file size: 10 MB.

– British Passport – EU Passport / EU ID Card with proof of settlement

Enter your digital share code*

Disclosure and Barring Service (DBS) Certified:*

Yes

Type of Disclosure?*

Standard

Enhanced

DBS Date of Issue:*

MM slash DD slash YYYY

Enter DBS Reference Number:*

Are you on the Update Service?*

Yes

Do you have a current full driving license:*

Yes

Do you have your own transport:*

Yes

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Proof of Address:

Please upload 2 (two) items stating your full name and current home address- Accepted Documents – A utility bill (gas, electric, satellite television, – Landline phone bill) issued within the last three months – Local authority council tax bill for the current council tax year – Bank, Building Society statement (last three months) – Original mortgage statement from a recognised lender issued for the last full year – HMRC correspondence within the current financial year (e.g. P45 / P60, self-assessment letter, tax demand, etc.)

Proof of Address 1*

Max. file size: 5 MB.

Proof of Address 2*

Max. file size: 5 MB.

SECTION 2 : Rehabilitation of Offenders Act

Have you ever been convicted of a criminal offence?*

Yes

Have you any prosecutions pending?*

Yes

Details of Offence(s) and Sentence

(This information will be disclosed by the Criminal Records Bureau check which will be required if successful. Please note a criminal record will not necessarily be a bar to employment)

SECTION 3: Health

Number of days absent in the last 2 years:

Are you registered disabled?*

Yes

If yes please provide your disability number and details:

SECTION 4: Education

Education and Training*

Please list your qualifications in reverse order, starting with the most recent first. Also, include any training that you have received which did not lead to a qualification but which you feel is relevant to the post. If short-listed for an interview, please be prepared to bring original copies of any certificates relating to post-school qualifications or vocational qualifications.

Date Obtained:

Place of study & address:

Examinations taken & grades:

Other Qualifications:*

Please give details of any other qualifications obtained or relevant courses attended.

Date Obtained:

Place of study & address:

Examinations taken & grades:

SECTION 5: Employment Record

Please list chronologically, starting with current or last employer*

Name of Employer:

Employer Address:

Length of Employment:

Salary:

Date From:*

DD slash MM slash YYYY

Date To:*

DD slash MM slash YYYY

Main Duties and responsibilities:

If currently employed how much notice are you required to give?

(weeks)

Reason for leaving or seeking new employment:*

5: List of Employer (Employment History): Note: Please click on the + sign to add more employment history.

Please give summary details of all your previous employment (most recent first for a minimum of 10 years if Applicable). Please ensure you include all part-time and temporary positions held, even those that are not relevant to your application. Please ensure you include any periods of unemployment or any other time that is not accounted for.

Name of Employer:

Employer Address:

Length of Employment:

Reason for leaving:

SECTION 6: Reference

(1) Referee:*

Please give the names and addresses of your two most recent employers (if applicable). If you are unable to do this, please clearly outline who your referees are.

Name of Referee:

Referee Job Title:

Email:

Telephone No:

Company Name:

Address:

May we contact your references prior to job offer:*

Referee 1:

Yes

(2) Referee*

The second referee can be your present employer or character reference (We will accept personal friends – No relatives.)

Name of Referee:

Referee Job Title:

Work Relationship:

Email:

Telephone No:

Organisation:

Address:

May we contact your reference prior to job offer:*

Referee 2:

Yes

SECTION 7: Emergency Contacts

Emergency Contacts/ Next of Kin:*

First Name :

Last Name:

Telephone Number:

Email:

Address:

SECTION 8: Personal Attributes

Please give details:

SECTION 9: Declaration

I confirm that the information provided in this application (and within my Curriculum Vitae if applicable) is both truthful and accurate. I have omitted no facts that could affect my employment. I understand that any false misleading statements could place any subsequent employment in jeopardy. I understand that any employment entered into is subject to documentary evidence of my right to work in the UK and satisfactory references. I expressly consent to personal data contained within this form being recorded for the purposes of assessing suitability for the post and may form the basis of any subsequent personnel file.

Signed:*

Enter Fullname as signature proof.

Date:*

MM slash DD slash YYYY

Chipet Care and Services Ltd undertakes that it will treat any personal information that you provide to us, or that we obtain from you, in accordance with the requirements of the Data Protection Act 1998. After initial assessment, Chipet Care and Services Ltd may keep your details on file for opportunities that may arise in the future. Please tick if you do not wish us to hold your details.*

Yes

Upload CV:

Accepted file types: pdf, doc, docx, jpg, Max. file size: 5 MB.

Filetypes: pdf, doc, docx, jpg

SECTION 10: Recruitment Monitoring Form

This sheet will be separated from your application form upon receipt and does not form part of the selection process. It will be retained by Human Resources purely for monitoring purposes.

Application for the post of:

To help us ensure that our Equal Opportunities Policy is fully and fairly implemented please COMPLETE THIS SECTION OF THE APPLICATION FORM.

What is your Ethnic Group?

Choose ONE section from A to E, and then tick the appropriate box to indicate your cultural background.

A: White

White UK

Irish

White -non-UK

Any other white background

(please give details):

B: Black or Black British

Black Caribbean

Black African

Any other Black background

(please give details):

C: Mixed

White & Black Caribbean

White & Black African

White & Asian

Any other Mixed background

(please give details):

D: Chinese or other ethnic group

Chinese

Vietnamese

Any other ethnic background

(please give details):

E: Asian or Asian British

Indian

Pakistani

Bangladeshi

Any other Asian background

(please give details):

F: I do not wish to provide this information

Section Break

Gender:

Male

Female

Are you registered disabled?*

Yes

If yes please provide your disability number and details:

Age Group:*

16- 25

26 – 35

36 – 45

46 – 55

56 – 65

66 – 70

over 70

Media:

Please sate where you saw this advised.

Asylum and Immigration Act 1996:

It is now a requirement that before any offer of employment can be made, all candidates are to provide confirmation of their eligibility to work in the UK. Please bring one of the following original documents with you if invited to interview: a passport or an immigration and nationality directorate application registration card which evidence the right to work in the UK or a UK residence permit issued to an EEA national which confirms right of entry to or residence in the UK.

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Phone

This field is for validation purposes and should be left unchanged.

2. Complete Pre-Employment Health Questionnaire Form

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PRIVATE AND CONFIDENTIAL

Position Applied For:

Title*

First Name:*

Last Name:*

Date of Birth:*

DD slash MM slash YYYY

Place of Birth:*

Country

Age:*

Please enter a number from 18 to 65.

Nationality:*

National Insurance (NI) No:*

Telephone Or Mobile Number:*

(Including STD Code)

General Practitioner Details:

General Practitioner:*

Address:*

Street Address City State / Province / Region ZIP / Postal Code Country

All candidates are required to complete the following questionnaire. All information will be treated privately and confidentially. All candidates are asked to answer each question by placing a tick in the relevant box. Should you answer Yes for any question, please give full details in the space provided on the next page.

Have you had your Covid vaccine*

YES

COVID Vaccine*

First Jab

Second Jab

COVID Booster

Please upload your NHS COVID- 19 Pass / Medical Exemption if unvaccinated:

Max. file size: 512 MB.

Have you suffered or are you suffering from any of the following:

Any skin disease (including dermatitis and eczema)?*

YES

Discharge or disinfection of the ear or hearing defect?*

YES

Asthma or hay fever or sufficient severity to require time off work?*

YES

Any allergies (including sensitivity to antibiotics or other drugs)?*

YES

Discharge from the nose, recurrent sore throat or sinusitis?*

YES

Bronchitis or pneumonia?*

YES

Tuberculosis?*

YES

Recurrent diarrhoea, vomiting or dysentery?*

YES

Typhoid, paratyphoid, hepatitis, entities, enteric fever?*

YES

Recurrent boils or septic infections?*

YES

Have you visited the dentist in the last 12 months?*

YES

Have you ever suffered from high blood pressure?*

YES

Have you ever been diagnosed as suffering from any type heart disease?*

YES

Do you suffer from persistent headaches or migraine?*

YES

Depression, nervous breakdown or mental illness, psychiatric treatment?*

YES

Arthritis, rheumatism, back problems or sciatica?*

YES

Are you aware of any reason why you cannot lift objects?*

YES

Rupture, varicose veins or foot ailments?*

YES

Indigestion or stomach pains?*

YES

Kidney infection?*

YES

Bladder infection?*

YES

Eye disease, injury or significant defects of vision not corrected by spectacles?*

YES

Date of last eye test*

MM slash DD slash YYYY

Diabetes?*

YES

Have you ever been admitted into hospital?*

YES

Have you ever had to stop work for more than one month for medical reasons?*

YES

Do you have any special needs or disability?*

YES

Are you currently under medication prescribed by your GP?*

YES

If you have answered YES to any of the questions, please provide details below: – Stating with the relevant question number

Declaration:

I understand and acknowledge that should I knowingly make a false statement regarding my medical history either in answering the above questions or to any medical examiner, or should I wilfully conceal any material fact, I will if engaged be liable to have my contract terminated. In the event of any health queries I consent to my general practitioner supplying relevant information to the company medical advisor. I confirm that there is nothing in my current circumstance that would be detrimental to me working either on a shift roaster basis throughout the night.

Applicant’s Name*

Applicant’s Date of Completion:*

MM slash DD slash YYYY

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3. Complete New Employee Form

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Employer : Chipet Care and Sevices Limited

PAYE Reference:

For Official use

Employee Details:

Title*

First Name:*

Last Name:*

Address

Street Address City ZIP / Postal Code Country

Phone*

Email*

Date of Birth:*

DD slash MM slash YYYY

Gender:*

Male

Female

Prefer not to say

National Insurance (NI) No:

Payroll Number:

(Office use only)

Contact Information(In case of emergency)

Name of person to contact:*

Relationship to you:*

Telephone*

Mobile Number:*

Bank Details:

Name of Bank:*

Account Holders Name:*

Account Number:*

Sort Code:*

Starter Declaration:

Tick one of the following three statements:

This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance, Employment and Support Allowance, taxable Incapacity Benefit, State or Occupational Pension.

This is now my only job but since last 6 April I have had another job, or received taxable Jobseeker’s Allowance, Employment and Support Allowance, taxable Incapacity Benefit. I do not receive a State or Occupational Pension.

As well as my new job, I have another job or receive a State or Occupational Pension.

Student Loans I make:

Type 1 Student Loan repayments through payroll

PostGrad Loan repayments through payroll

Type 2 Student Loan repayments through payroll

P45:

I attach a copy of the P45 from my previous employer

Employment Start Date:

MM slash DD slash YYYY

Declaration:

Sign:

Print Full name

Date

MM slash DD slash YYYY

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4. Complete Non-Disclosure Form

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Non-Disclosure Form

During the course of my engagement with Client (referred to as the ‘Client’), I may learn of confidential information relating to the Client. Confidential information includes matters not generally known outside the Client, and includes various developments, inventions, improvements, methods, etc., relating to products, services marketed or used by the Client (e.g. relating to sales, costs, profits, organisation, customer lists, pricing methods, etc.). I agree not to disclose any confidential information to others or to make use of it either during or after my engagement by the Client, whether or not such information is produced by my own efforts, except as expressly permitted in writing by the Client. Also, I may learn of apparatus, methods, ways of business, etc., which in themselves are generally known but whose use by the Client is not generally known, and I agree not to disclose to others such use, either during or after my engagements. All inventions, discoveries, developments and improvements (hereafter referred to as ‘Inventions’) made or conceived during the course of my engagement with the Client, whether the same are patentable or not, shall become and remain the sole and exclusive property of the Client. I agree to notify immediately the Client in writing of such Inventions, and hereby transfer all rights title and interest in and to any such Inventions to the Client. I hereby assign to the Client all rights title and interest in and to all copyrights on all writings, documents, reports, computer programs and other works made or written by me during the course of my engagement with the Client. My obligations under this Agreement shall survive the termination of my engagement with the Client regardless of the manner of such termination, and shall be binding upon my heirs, executors and administrators.

Signed:

Printed Name as the signature.

Name:

Date

DD slash MM slash YYYY

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Registration Process For Recruitment

The information you supply on this form will be treated in confidence.

SECTION 1 : Personal Details

Proof of Address:

SECTION 2 : Rehabilitation of Offenders Act

SECTION 3: Health

SECTION 4: Education

SECTION 5: Employment Record

SECTION 6: Reference

SECTION 7: Emergency Contacts

SECTION 8: Personal Attributes

SECTION 9: Declaration

SECTION 10: Recruitment Monitoring Form

Application for the post of:

What is your Ethnic Group?

Section Break

Asylum and Immigration Act 1996:

PRIVATE AND CONFIDENTIAL

General Practitioner Details:

Have you suffered or are you suffering from any of the following:

If you have answered YES to any of the questions, please provide details below: – Stating with the relevant question number

Declaration:

Employer : Chipet Care and Sevices Limited

Employee Details:

Contact Information(In case of emergency)

Bank Details:

Starter Declaration:

Declaration:

Non-Disclosure Form

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