Support Worker – Wolverhampton Job Ref : AJCM/SAL/RACJ/0319 Job Reference Number Title (please specify e.g. Mr) Your Name (required) Previous Surname(s)/Family Name(s) Do you need a UK work permit or Visa? If yes, date of expiry Home telephone (required) Mobile (required) Your Email (required) Your Address Please answer the following question if the job description/person specification for the job states this as either essential or desirable: Do you hold a current full driving licence? YesNo Do you currently have endorsements? YesNo If Yes, please give details including expiry date(s) Do you have access to a vehicle for work purposes? YesNo Have you ever had an application for Motor Insurance either cancelled or refused. YesNo If Yes, please give more information Education Qualifications - Enter Course and Grades Membership of Professional Bodies: Nursing/Midwifery If Applicable. Enter Name, Renewal Date, Membership/Status and Pin Number. Work History Please enter dates, name and address of employers and job role. Enter a reason for leaving. Gaps in work history or experience Enter dates and reasons. Supporting Statement Please set out below any further information which you feel supports your application. In particular, you should provide examples to illustrate how you meet the competencies and experience set out in the Person Specification and Job Description. Current / Previous Employer References Current/Previous Employer (1) Enter Name, Job title, Address, Telephone Number and Dates of Employment. Current/Previous Employer (2) Enter Name, Job title, Address, Telephone Number and Dates of Employment. References; we require references which cover at least 3years of your employment. One reference must be your present or most recent employer. If this is your first job since leaving full time education, your head teacher or further education tutor should be given as referee. Your personal reference must be someone who knows you well. After interview and prior to any conditional offer of employment, can we contact your current employer (see note below)? Employment referees will be requested to provide details on, salary, performance, and, where applicable, reasons for leaving. Where relevant, referees will be asked for/ about their knowledge of your work and suitability to work with children, young people and vulnerable adults. YesNo If you are shortlisted, are there any special arrangements we would need to make for your interview and any selection tests? (If Yes, and you are successful in obtaining an interview, we will contact you to discuss your stated needs)? YesNo Where did you see the post advertised Notice Period: If appointed, how soon could you take up your new post Do you have any criminal convictions YesNo If yes, please give details below of any criminal convictions, cautions or bind over orders. The post applied for is exempt from the provisions of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986 and therefore you are required to disclose your criminal background, if any. We undertake not to discriminate unfairly on the basis of conviction or other information received. We have a policy statement on the recruitment of ex-offenders a copy is available on request. For all staff working with children and vulnerable adults a Disclosure Barring System (DBS) current Disclosure check will be required before taking up employment. We have a policy statement on the secure storage, handling, use and retention & disposal of Disclosures and Disclosure information. Declarations Data Protection "I give permission for AJ Case Management Ltd to process and hold on computer the information or data I have supplied or referred to on it, including any information that I consider to be sensitive and personal. I understand and agree that this information will also be held on my personal file, if I am appointed." "I agree that AJ Case Management Ltd may use the information provided in this application form for equality monitoring purposes, compiling statistics, maintaining other employment records and completing statutory returns as required." “Should I be unsuccessful in this position I give permission to AJ Case Management to keep my records on file and contact me with information on any future positions unless I state otherwise” References "I agree that AJ Case Management Ltd may ask my referees for comments on my suitability for the post and in respect of employment referees request details on my salary, performance, conduct, reasons for leaving and suitability to work with children, young people and Vulnerable adults, where applicable." Application submission "In submitting this application form, I confirm that the information I have given is correct and complete and I understand that giving misleading or untruthful statements may result in my dismissal if they become known after my appointment." Please check your spam box - You will receive an email with more info and confirming that we've received your application. Agreement: I Agree Name Date Please attach a copy of your CV here For electronically submitted forms you will, if shortlisted, be asked to provide a signature at interview.