AJS Support Services

Title		Surname

Title

Surname

First name

Middle name(s)

Date of birth

Gender

House name or no.

Date of residence

Street

Tel home

Town

Tel work

County

Tel mobile

Postcode

Country

Email

What job/s are you applying for?

Name

Tel home

Relationship to you

Tel mobile

Email

Registration number

Expiry/Renewal date

Insurance provider

Insurance policy number

Expiry date

Where did you hear about us? (Please specify where relevant)

Do you hold a British/EU passport?

Yes No

Nationality

Passport no.

Expiry date

If you do not hold a British/EU passport, do you hold any of the following?

Evidence is required of all passports and visas. Please enclose or send scanned copies or photocopies with this application and bring the originals to your first interview. To work, you will be expected to communicate proficiently in English. All passports and visas will be verified as part of our recruitment procedure.

List all professional qualifications held and training courses undertaken, including Post Graduate Diploma/Courses etc. Professional qualifications and training will be verified. Continue a separate sheet if necessary. Please provide scanned copies/photocopies of all certificates.

Qualification

Place were obtained

Date to/from

Appraisal

You are required to complete the following practical training on an annual basis. (Please tick the relevant courses you have completed and that you will be sending us a valid original certificate)

Manual Handling

Place obtained

Date to/from

Basic life support

Immediate Life Support (if applicable)

Food Hygiene

Safeguarding Children and Young People (POCA) Level 2

Safeguarding Children and Young People (POCA) Level 3

Protection of Vulnerable Adults (POVA)

Complaint’s handling

COSHH

Fire Safety

Health & Safety

RIDDOR/Risk Incident Reporting

Violence & Aggression

Information Governance, Data Protection & Caldicott Protocol

Infection Control (including Clostridium Difficle & MRSA)

Lone Worker Training

Additional Training 1

Additional Training 2

Additional Training 3

MOST RECENT FIRST. Please list the last 10 years of your employment, including secondary school. It is important that you explain any gaps of employment of over 1 month in duration. In addition, please attach your current CV.

1. Employer’s details

From (Month/Year)

To (Month/Year)

Employer

Location (Ward/Dept.)

Job title

Telephone no

Grade/Band

Email

2. Employer’s details

From (Month/Year)

To (Month/Year)

Employer

Location (Ward/Dept.)

Job title

Telephone no

Grade/Band

Email

3. Employer’s details

From (Month/Year)

To (Month/Year)

Employer

Location (Ward/Dept.)

Job title

Telephone no

Grade/Band

Email

4. Employer’s details

From (Month/Year)

To (Month/Year)

Employer

Location (Ward/Dept.)

Job title

Telephone no

Grade/Band

Email

5. Employer’s details

From (Month/Year)

To (Month/Year)

Employer

Location (Ward/Dept.)

Job title

Telephone no

Grade/Band

Email

Please give the names and contact details of three professional referees from your current and most recent employment, which must cover the last 5 years of employment/education. Referees must have worked in a senior position to yourself. Please be aware that AJS Community Support Care Services Ltd are unable to offer you work until satisfactory references have been obtained, and that AJS Community Support Care Services Ltd are required to obtain references for you on an annual basis. Please continue a separate sheet if necessary.

Reference 1

Organisation

Job title

Ward/Dept

Grade/Band

Dates Employed (Month/Year)

Referee name

Professional title

Email

Telephone

Capacity in which known (i.e., Manager)

Can we contact prior to interview?

Yes No

Reference 2

Organisation

Job title

Ward/Dept

Grade/Band

Dates Employed (Month/Year)

Referee name

Professional title

Email

Telephone

Capacity in which known (i.e., Manager)

Can we contact prior to interview?

Yes No

Reference 3

Organisation

Job title

Ward/Dept

Grade/Band

Dates Employed (Month/Year)

Referee name

Professional title

Email

Telephone

Capacity in which known (i.e., Manager)

Can we contact prior to interview?

Yes No

National Insurance number

Please visit www.trustcaresolutions.co.uk to select an umbrella company to work through.

Do you wish to nominate an umbrella company?

Yes No

Please name

Do you wish to work as a limited company?

Yes No

Please provide a copy of your: (please tick)

Applicants for Healthcare positions are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare prosecutions or convictions, including those considered ‘spent’ under this Act. Please tick.

1. 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) by SI 2013 1198?

Yes No

2. Do you have any convictions, cautions, reprimands, or final warnings which would not be filtered in line with current guidance?

Yes No

3. Have you had a Police check in another country within the last 6 months? If so, please provide details below and enclose a copy if held.

Yes No

4. Have you ever been suspended or are you currently under investigation by an ICS Trust, professional body, or any other organisation?

Yes No

5. Have you ever had an Enhanced Disclosure and Barring Service (DBS) check? (Formerly Criminal Records Bureau check or CRB)

Yes No

Disclosure no.

Date

Company that conducted the check:

If you have signed up for the DBS Update Service, please provide the details of your DBS number:

AJS Community Support Care Services Ltd Will undertake an Enhanced DBS check on your behalf. You will not be placed without having completed a current DBS check. Please contact your recruitment team to check the process for completing the DBS application online. Please enclose all ORIGINAL documentation (e.g., passport) as requested, not just photocopies. These will be returned to you immediately. Please note that at any stage whilst working for AJS Community Support Care Services Ltd receive a DBS enhanced disclosure that highlights information you have not declared then you will be removed from your assignment.

Working Time Directive

The Working Time Regulations 1998 require AJS Community Support Care Services Ltd limit your average weekly working time to 48 hours unless you agree with AJS Community Support Care Services Ltd that the limit shall not apply to you:

I agree to limit my working week to no more than 48 hours I disagree to limit my working week to no more than 48 hours

Candidate Handbook

Please download, print, and sign the Candidate Handbook from our website. You will need to return this with the application pack.
I can confirm that I received, read, and understood each section of the Candidate Handbook:

Before you start a temporary assignment Policies and Procedures Assignments Appraisals and Training Benefits of working for AJS Community Support Care Services Ltd

I can confirm that I have read this document fully and that all the information provided to AJS Community Support Care Services Ltd is correct and to the best of my knowledge and belief. I give consent to contact referees regarding the information I have provided unless specified otherwise.
I will inform AJS Community Support Care Services Ltd should anything change that might affect my position and I understand the information given on this form will be processed by computer and used for registration purposes, under the Data Protection Act 1998.

1. I understand that if I am at any stage charged or cautioned after signing this declaration, I must inform AJS Community Support Care Services Ltd.
2. I acknowledge that I have been given a copy of the terms and conditions of service issued by AJS Community Support Care Services Ltd, which is mine to keep, and furthermore that I have read those terms and conditions and agree to abide by them.
3. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my Occupational Health Form.
4. I acknowledge and confirm that AJS Community Support Care Services Ltd is authorised to apply for and obtain a Disclosure and Barring Service (DBS) check and references from any previous employers and educational establishments.
5. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future that AJS Community Support Care Services Ltd may cease to offer me further agency placements without notice, as well as claim for recovery of any payments I have received, together with a claim for loss of profit to AJS Community Support Care Services Ltd.
6. I agree that the maximum weekly working time specified in Regulation 4(1) and (2) of the Working Time Regulations 1998 shall not apply to working with AJS Community Support Care Services Ltd unless specified above.
7. I acknowledge that my personal details will be stored and handled correctly by AJS Community Support Care Services Ltd in accordance with the Data Protection Act 1998, however, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents - DBS, Occupational Health, References).
8. I understand that if I am on a student visa, I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student change, I must inform AJS Community Support Care Services Ltd.
9. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform AJS Community Support Care Services Ltd.
10. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for AJS Community Support Care Services Ltd , I must inform AJS Community Support Care Services Ltd immediately.
11. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will inform AJS Community Support Care Services Ltd if I am under investigation or suspended by me professional regulatory body or employer at any point while working for AJS Community Support Care Services Ltd.
12. I confirm that when asked about my working history (primarily, but not exclusively, for the purpose of the Agency Workers Regulations) I will provide accurate information.
13. I acknowledge that should I reach the 12-week Qualifying Period under the Agency Workers Regulations, I may be asked for, and will provide, further documentation as evidence of qualifying weeks, if AJS Community Support Care Services Ltd deem it necessary.
14. I confirm that whilst working for AJS Community Support Care Services Ltd I am willing to work through any of the brands/subsidiary companies that form part of AJS Community Support Care Services Ltd of companies. I understand that I will be informed at the time of placement which company/ brand that I will be working for and will be provided with the relevant documentation to represent that company.

Application Form

DOWNLOAD FORM