Do you require sponsorship to work in the UK?* Do you hold a valid UK driving licence? 1. Eligibility We are required by law to verify your eligibility to work in the United Kingdom before employment can commence.
Are you legally eligible to work in the UK?* 2. Role & Availability Tell us about the role you are applying for and your availability.
What role are you applying for?* Select an option Care Assistant Senior Carer Live-in Carer Night Carer Domiciliary Carer Healthcare Assistant Nurse Other
What employment type do you prefer?* Select an option Full Time Part Time Bank / Ad-hoc
Preferred weekly hours Select an option Full Time (37.5–40 hrs/week) Part Time (20–30 hrs/week) Part Time (16–20 hrs/week) Part Time (8–16 hrs/week) Weekend Only (Sat & Sun) Weekdays Only (Mon–Fri) 4 Hours Per Day 6 Hours Per Day 8 Hours Per Day (1 shift/day) 12 Hours Per Day (long shift) Bank / Ad Hoc (as needed) Flexible / Open to Discussion
Shift availability* Select an option Early (7am-2pm) Late (2pm-10pm) Nights (10pm-7am) Weekends Bank Holidays Flexible / Any
What is your notice period at your current job?
Do you have any pre-booked holidays or commitments? Do you have your own transport? Select an option Own car Motorcycle / bicycle Public transport Other
4. Employment History Please provide details of any gaps or dismissals in your employment history.
Have you ever been dismissed from employment?* Please explain any gaps in your employment history Include approximate dates and reasons (e.g. caring responsibilities, education, travel)
5. Skills & Qualifications Please tick all that apply. Include dates where shown.
Do you have Manual Handling training? Do you have Basic First Aid training? Do you have Basic Food Hygiene training? Do you have Medication Administration training? Do you have Dementia Awareness training? Do you have Safeguarding Adults training? Do you hold NVQ/QCF Level 2 or above in Health & Social Care? Do you have an enhanced DBS certificate? If yes, what type of DBS do you hold? Select an option Basic Standard Enhanced
Is your DBS registered with the Disclosure and Barring Service Update Service? DBS Certificate Number
Workforce Type (as stated on your DBS certificate) Select an option Adult Workforce Child Workforce Both Not sure
Are you a Registered Nurse (NMC)? 6. Criminal Convictions (DBS Disclosure) Under the Rehabilitation of Offenders Act 1974 (Exceptions) Order, all convictions including spent convictions must be declared for roles in regulated activity with vulnerable adults or children.
Do you have any criminal convictions, cautions or reprimands?* 7. Medical Details This information is used to assess fitness for the role and to identify any reasonable adjustments that may be required under the Equality Act 2010.
Do you currently enjoy good health?* Do you have any conditions that may affect your ability to perform care duties? Are you currently taking any medication? 8. Source & Documents Let us know how you found this opportunity and upload any supporting documents.
How did you hear about us? Select an option Indeed / Job Board Company Website Social Media Employee Referral Job Centre Walk In / Phone Recruitment Agency Other
Upload your DBS certificate PDF or image, max 5MB
Upload proof of right to work Passport, BRP, or Share Code confirmation
Upload relevant qualification certificates NVQ, Care Certificate, First Aid, etc.
EMPLOYMENT REFERENCE REQUEST Strictly Confidential
Applicant Name:*
Position Applied For
Reference Type Reference Type Personal Professional Employer
Prepared by Select an option Haverhill Home Care Recruitment
Contact*
Please confirm employment dates (Leave the same if dates are correct):
What was their reason for leaving?
Are you aware of any recent/outstanding allegations that were made against the applicant that relates to safeguarding issues/ or referrals (including any referrals to the disclosure and barring service or independent safeguarding authorities)? Select an option Yes No
Is the applicant currently under any investigation for any matters (including conduct, capability or performance) under any of your employment policies? Select an option Yes No
Is there any further information that you feel is relevant to the applicant's suitability to work in this capacity?
Are you happy for us to contact you on the information that has been provided? Select an option Yes No
Standard of work Select an option Excellent Good Fair Poor
Attitude to work Select an option Excellent Good Fair Poor
Attitude to colleagues Select an option Excellent Good Fair Poor
Safety record Select an option Excellent Good Fair Poor
Name of individual completing reference:
Job title:
Company Name:
Relationship to candidate (e.g. manager, HR etc.)
Did/do you line manage the candidate? Please confirm that you supervise this candidate in work: Contact phone number and professional email:
NMC Pin:
The answers given above have been provided in good faith and are correct to the best of my knowledge and belief. By signing this form you consent to the information contained within it being stored in Florence. Florence will use this information to verify the person's employment with you. Also by signing below, the information you have provided may additionally be shared with this person and their prospective clients.
Referee name
Date:
