Pine Lodge v1

Vacancy

Position applied for:
TemporaryPermanent

Location applied for:
FullPart time

About you

Title:
First Name:
Last Name:
Place of Birth:
National Insurance Number:

Have you been known by other surnames?
yesNo
If Yes, Please state including dates and previous names
Date of Birth

Home Address

Current Address:
City:
County:
Email Address:

Postal Code:
Home Telephone number:
Mobile Number:

Other Details

Do you have a current driving licence?
Do you have the right to work in the UK?

Is your driving licence for a Manual or Automatic Vehicle?
Are you related to anyone currently working for The Hennessy Group?

If Yes, Please state:

Next of Kin

Name:
City:
Telephone number:

Address:
Postal code:
Relationship to applicant:

Previous address History

Please list your address history covering the last 5 years in chronological order, running month to month:

Cautions and Convictions

Rehabilitation of Offenders Act 1974 (exceptions) Order 1975

Due to the nature of The Hennessy Group’s work with children and young people, we use the Disclosure and Barring Service to make checks at an enhanced level on all persons offered employment by The Hennessy Group. Please declare all warnings, cautions, whether spent or not.

You must complete all sections of this form. Failure to do so may result in a delay in processing your application.

Have you ever been convicted, charged, cautioned, warned or prosecuted for an offence?

If Yes, Please give details:

Safeguarding Children

Education from 11 to 19 Years of age

Name of school/college attended and full address:
Subjects studied:

Dates from and to:
Grades:

Further Education

Name of College/University:
Subjects studied:

Dates from and to:
Grades

Professional Qualifications

Name of Qualification:
Level:
Date achieved:

Employment

Please list below all your employment and voluntary roles including those overseas, in chronological order, starting with the most recent first going back to leaving education. You must include details of any gaps or breaks in service giving full reasons, including those outside of employment. There cannot be any unexplained gaps in your employment history.

Please note as part of our checks we contact all former Health and Social care providers that you have worked for.

Employer Details

Name of Current Employer:
Address:
Postal Code:
Start Date:
End Date:
Reason for leaving or intention to leaveYesNo

Job Title:
City:
Employers contact email:
Employers contact number:
Notice period required:
Salary:

Employment History

Name of Employer:

Job Title:

Address:

City:

Postal Code:

Start Date:

End Date:

Reason for leaving:

Employers contact email:

Employers contact number:

Notice period required:

Salary:

Briefly describe your role:

Name of Employer:

Job Title:

Address:

City:

Postal Code:

Start Date:

End Date:

Reason for leaving:

Employers contact email:

Employers contact number:

Notice period required:

Salary:

Briefly describe your role:

Name of Employer:

Job Title:

Address:

City:

Postal Code:

Start Date:

End Date:

Reason for leaving:

Employers contact email:

Employers contact number:

Notice period required:

Salary:

Briefly describe your role:

Name of Employer:

Job Title:

Address:

City:

Postal Code:

Start Date:

End Date:

Reason for leaving:

Employers contact email:

Employers contact number:

Notice period required:

Salary:

Briefly describe your role:

Employment History Continuation sheet:

Please continue to list your previous employment in chronological order. Please use this sheet to explain any gaps in employment.

All dates should run concurrently and should be dated by at least the month the employment or gap started and ended.

Working Overseas

Have you ever worked overseas? If yes please give details and dates:

References

Please provide details of three persons to whom references may be made. The first MUST be your current employer (Head Teacher, College Principal, Manager or Chair of Governors). Your second reference should be a previous employer. They should be different organisations wherever possible.

The third referee should be a character reference, who is not a member of your family.

It is also necessary for us to contact all previous employers regarding your period of employment working with vulnerable children and/or adults.

Current Employer Reference

Name:
Job Title:
Address:
Telephone Number:

City:
Postal Code:
Email address:

Previous Employer reference

Name:
Job Title:
Address:
Telephone Number:

City:
Postal Code:
Email address:

Character reference

Name:
Job Title:
Address:
Relationship to applicant:

City:
Postal Code:
Email address:
Telephone Number:

Training and Achievements

Please provide a list of current training you have attended relevant to the job role and any notable achievements:

Declaration

I declare that to the best of my knowledge and belief that the information provided by me in this application is true and accurate, and I understand that the above information forms the basis of any offers of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.

I understand that I cannot be offered a post until a satisfactory response has been received with respect to my Enhanced DBS check, and that should I subsequently be offered a post, that offer will be subject to receipt of three satisfactory references, one of which must be from my current employer.

If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers.

By my signature, I authorise the organisation to request an enhanced DBS check before employment starts and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence including motoring offences, the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status.

I have read and understand the statement above:

Signed:
Date:

Equal opportunities monitoring

We are committed to equal opportunities in our recruitment process and in order to find out how well we are doing with this we need to collect monitoring data. This monitoring form is voluntary but the information we collect here is very useful to us as it helps us to make sure that we are an inclusive employer and to find out if our workforce is diverse. The information you supply on this form will be kept confidentially. The monitoring form is not sent to the recruiting panel and has no part in the shortlisting process.

How did you find out about this post?

Hennessy Group websiteOnline publication/job-board (please state)Other (please state)

Your ethnic origin

These categories are based on the Census 2011 categories and recommended by the Commission for Racial Equality.

Asian, Asian British, Asian English, Asian Scottish, or Asian Welsh White

Black, Black British, Black English, Black Scottish, or Black Welsh Mixed

Your gender

MaleFemalePrefer not to say

Have you ever identified as transgender?

YesNoPrefer not to say

Your age

Date of Birth

16-2425 - 3435 - 4445 - 5455 - 6465+Prefer not to say

Your sexual orientation

BisexualGay manGay woman/lesbianHeterosexual/straightOtherPrefer not to say

Marriage and civil partnership

SingleMarried/in a registered same-sex civil partnershipSeparated, but still legally married/in a registered same-sex civil partnershipDivorced/formerly in a same-sex civil partnership which is now legally dissolvedWidowed/Surviving partner from a same-sex civil partnershipPrefer not to say

Your religion or belief

NoreligionBuddhistChristian (including Church of England, Catholic, Protestant and all other Christian denominations)HinduJewishMuslimSikhOther (specify if you wish)Prefer not to say

Your experience of mental health problems

Would you describe yourself as someone who is experiencing or has experienced mental health problems?

Yes

Please state how Hennessy Group can support you in your employment:

NoPrefer not to say

Disability

The Equality Act 2010 defines a disabled person as someone who has a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.

Do you consider yourself to be disabled? YesPlease specifyNoPrefer not to say

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