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Care Homes
Abbey View | Bangor
Aughnacloy House | Lurgan
Beverly Lodge | Newtownards
Burleigh Hill House | Carrickfergus
Hollybank Manor | Newtownards
Rathmena House | Ballyclare
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Job Opportunities
Northern Ireland's Leading Health & Social Care Organisation
Filling in an Application Form
Application Form
1
Personal Details
2
Additional Details
3
Next of Kin
4
Convictions/Investigations
5
Employment
6
Criteria
7
References
What role have you applied for?
(Required)
Personal Details
Name
(Required)
Dr
Miss
Mr
Mrs
Ms
Prof.
Rev.
Title
First
Last
Maiden Name (if applicable)
Home Phone Number
Mobile Number
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City/Town
County
Postcode
Right to Work
(Required)
I confirm that i have a right to work in the UK.
Do you require sponsorship?
(Required)
No
Yes
Unfortunately you have indicated your require sponsorship. We can not offer sponsorship for this role so we will therefore not be able to progress with your application.
Additional Details
Your National Insurance Number:
(Required)
Are you registered with NMC or NISCC?
(Required)
Yes
No
What is your NMC/NISCC number?
(Required)
What is your NMC/NISCC certificate expiry date?
(Required)
DD slash MM slash YYYY
Do you have your own form of transport?
(Required)
Yes
No
Driving Licence No.
Have you worked for an agency within the last 3 months?
(Required)
Yes
No
Which agency or agencies did you work for?
(Required)
Next of Kin
Name
(Required)
Maiden Name (if applicable)
Address
(Required)
Contact No.
(Required)
Relationship to you:
(Required)
Consent
(Required)
Please tick to confirm that the person named has given their consent to be contacted as your next of kin.
Convictions/Investigations
INVESTIGATIONS/REPORTS
1. Have you ever been the subject of an Adult or Child Abuse investigation or been previously referred to the Independent Safeguarding Authority/DBS as a result of misconduct involving a child or a vulnerable adult?
(Required)
Yes
No
If yes, provide full details below:
(Required)
2. Have you ever been reported to NMC/NISCC?
(Required)
Yes
No
If yes, provide full details below:
(Required)
CONVICTIONS/OFFENCES
Due to the services provided the majority of posts within the Company are governed by the Protection of Children & Vulnerable Adults (NI) Order 2003 and the Rehabilitation of Offenders (Exceptions) Order NI 1979. Disclosure of offences will not automatically debar you from applying for the post.
Do you have any convictions that are not “protected” as defined by the Rehabilitation of Offenders (Northern Ireland) Order 1978, as amended in 2014?
(Required)
Yes
No
If yes, provide full details below:
(Required)
All disclosures will be reviewed for compatibility with the post.
Employment History
Our governing body, RQIA requires all applicants to provide a full employment history. Please detail your employment history from when you left school to present.
Please also include periods of time when you were not in paid employment, caring for relatives, time spent in education/training, travelling or volunteering at home or abroad.
Current/Most Recent Employer
No Employment History
Please check this box and move onto the next part if you have never had a job before.
Current/Most Recent Employer
Job Title
Employer (name & address)
Start Date (dd/mm/yy)
End Date (dd/mm/yy)
Hourly Rate/Salary
Reason for leaving
Previous Employers (please list all since leaving school starting with most recent))
Job Title
Employer (name & address)
Start Date (dd/mm/yy)
End Date (dd/mm/yy)
Hourly Rate/Salary
Reason for leaving
Add
Remove
Please click on the + button to add more employers.
Do you need to add anymore employers to your employment history?
(Required)
Yes
No
Please complete a paper application form with your remaining previous employers.
Break in Employment
Do you need to provide details of any periods you were not working since leaving school?
(Required)
Yes
No
Date from
(Required)
DD slash MM slash YYYY
Date to
(Required)
DD slash MM slash YYYY
Please provide details for this break in employment:
(Required)
Do you need to provide any further details of period you were not working?
(Required)
Yes
No
Please provide further details of dates and reasons for further periods of not working:
(Required)
Job Criteria
Please provide any other information which may be relevant to this application, detailing how you meet each of the criteria:
(Required)
Qualifications
Course
Qualification gained
Place of study
Dates Attended (mm/yy – mm/yy)
Add
Remove
Please provide information on the qualifications you hold.
References
Please complete the details of two reference which must include your present/most recent employer. • Relatives cannot be named as referees. • Character references can be sought from a GP, religious official or friend who is not a relative.
We will only seek references after an offer of employment is accepted. We may seek references from your previous employers if one from your current/most recent employer is unobtainable. Please note we are required to obtain a reference from all previous employments within Health & Social Care. Please complete reference details in full.
Please tick the box to allow us to complete and receive references for you:
Reference 1 (Most Recent Employer)
Name of Reference 1 (Most Recent Employer)
(Required)
Company Name
Address (inc. postcode)
(Required)
Telephone Number
(Required)
Email address
(Required)
Capacity Known
(Required)
How does this person know you?
Employed From
DD slash MM slash YYYY
Employed To
DD slash MM slash YYYY
Reference 2 (Character/Employer)
Is this a character or employer reference?
(Required)
Character
Employer
Name of Reference 2 (Employer/Character)
(Required)
Company Name
Address (inc. postcode)
(Required)
Telephone Number
(Required)
Email address
(Required)
Capacity Known
(Required)
How does this person know you?
Employed From
DD slash MM slash YYYY
Employed To
DD slash MM slash YYYY
Consent
(Required)
Please tick the box to allow us to complete and receive references for yourself.
Declaration
Declaration
(Required)
I confirm I understand and accept offers of employment and subsequent appointment will be subject to the outlined declaration.
Declaration:
Offers of employment and subsequent appointment will be subject to:
– The information I give being correct and any omissions, misleading or false information may provide grounds for withdrawal of offer or termination of employment.
– Satisfactory references, Enhanced Access NI disclosures, evidence document checks, medical information and relevant registration checks as deemed acceptable to the company.
– Training and/or induction will not be paid :
• If pre-employment checks are not satisfactory.
• If you do not complete the induction process.
• If we withdraw offer of employment.
• If you do not complete induction to a satisfactory standard.
• If you do not commence employment with the company.
– Registration with the appropriate body as required under statutory regulation i.e. NMC/NISCC.
-Access NI: Should you be successful in obtainning a position with the company any offer will be subject to receipt of a satisfactory Enhanced Access NI check and employment may not commence until the disclosure has been received. You will be required to complete an application for an Enhanced Access NI check if you are invited to interview. All information provided will be kept in the strictest confidence and only be used for the purposes of assessing your suitability for the post you have applied.
The company has a policy on the Recruitment of Ex-Offenders which is available on request.
Access NI have a written Code of Practice which can be downloaded from the following website: https://www.nidirect.gov.uk/
– The company’s Access NI Data Policy and GDPR Privacy Notice for Job Applicants is available to view on the company website: www.domesticcareni.com, located in the footer (bottom of the website).
Please note: We reserve the right not to shortlist due to an incomplete application form.
How did you become aware of this job role?
(Required)
Please Select
Indeed.com
Facebook
Other social media platform
jobapplyni.com
Staff Member
Google Search
Friend or Family member
Other
Name of staff member who referred you:
(Required)
Signature
(Required)
Date
(Required)
DD slash MM slash YYYY
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