Application Sections Application Form You can navigate through each section of the application form below: Section 1. Personal Details View 2. Availability View 3. Motor Vehicle View 4. Employment View 5. Education View 6. About You View 7. References View 8. Convictions View 9. Medical View 10. Voluntary View 11. Declaration View Personal DetailsNOTE: Because of the nature of the work for which you are applying, this post is exempt from the provisions of section 4(2) of the Rehabilitation of Offender Act, 1974 by virtue of the rehabilitation of offenders act 1974 (Exemptions) order, 1975. Applicants are, therefor not entitled to withhold information about convictions which for other purposes are “spent” under the provisions of the Act, and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by the Company. Any information given will be completely confidential and will be considered only in relation to an application for positions for which the order applies.ApplicationIDDate of application Date Format: DD slash MM slash YYYY IPAddressPosition Applied ForApplicant Name* Title Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Applicant Address* Street Address Address Line 2 City County Post Code Applicant Mobile* Please enter a valid phone number! Applicant Telephone Please enter a valid phone number! Applicant Email* Date Of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeNational Insurance Number*Gender*MaleFemalePrefer Not to AnswerMarital Status*SingleMarriedDivorcedWidowedNationality*AfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanCitizen of Antigua and BarbudaArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianCitizen of Bosnia and HerzegovinaBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseColombianComoran Congolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanCitizen of the Dominican RepublicDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadiaGuamanianGuatemalanCitizen of Guinea-BissauGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianCitizen of KiribatiKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianCitizen of SeychellesSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt Lucian Stateless SudaneseSurinameseSwaziSwedish SwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenCitizen of VanuatuVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabweanAre you legally eligible for employment in the UK?*YesNo AvailabilityPlease select details of when you are available to work. Due to the nature of the service we provide to the community the company may be requested to provide home care at short notice.Type of employment required* Full Time Part Time Seasonal Number of weekly hours required* 20-25 (Minimum hours) 25-30 30-35 35-40 40+ Which areas do you prefer to work in?*You MUST select at least 2 areas. Wherever possible we will try our best to keep you in the area of your choice but there may be circumstances where you may need to work in different areas based on current business circumstances and staff availability. Select All Hodge Hill Shard End Ward End Washwood Heath Small Heath Sparkbrook Sparkhill Bordesley Green Stechford Yardley Sheldon Acocks Green Hall Green Kings Heath Weekday Availability Please select your weekday availability during Monday to Friday. Info! You MUST select at least 2 EVENING shifts Monday to Friday. Morning Shift (7am - 11am) Select All Monday Tuesday Wednesday Thursday Friday Lunch Shift (11am - 2pm) Select All Monday Tuesday Wednesday Thursday Friday Tea Shift (2pm - 6pm) Select All Monday Tuesday Wednesday Thursday Friday Evening Shift (6pm - 10pm)You MUST select at least 2 EVENING Shifts between Monday and Friday. Select All Monday Tuesday Wednesday Thursday Friday Weekend Availability Please select your weekday availability during Saturday and Sunday. Info! You MUST select at least 3 shifts on Saturday and/or Sunday and 1 MUST be an EVENING shift. Morning Shift (7pm - 11pm) Select All Saturday Sunday Lunch Shift (11am - 2pm) Select All Saturday Sunday Tea Shift (2pm - 6pm) Select All Saturday Sunday Evening Shift (6pm - 10pm)You MUST select at least 1 EVENING shift Saturday or Sunday. Select All Saturday Sunday Date available to start work*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Due to the nature of the service we provide to the community the company may be requested to provide home care at short notice. Would you be willing to respond at short notice?*YesNo Motor VehiclePlease complete any motor vehicle detailsDo you hold a valid license to drive a motor vehicle*YesNoDo you at present have access to a car for work?*YesNoDetails of any endorsementsPlease upload your car documentsWe require: Copy of your driving license Copy of your MOT certificate Copy of your car insurance You must also present these documents at the interview. Drop files here or What is your current employment status?*Employed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to AnswerHave you ever been employed?*YesNoMost Recent EmploymentTell us about your current or most recent employment.Company Name*Company Address* Street Address Address Line 2 City County Post Code Telephone*Date started*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you currently working in this position?*YesNoDate endedDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DurationMonthsYour Job Title*Line Manager Name* Title MrMrsMissMsDrProf.Rev. First Last Line Manager Email Please enter a valid phone number! Summarise the nature of the work performed, your job responsibilities, giving a reason for leaving*Employment HistoryDo you had any other previous employers?*YesNoPrevious EmploymentTap 'ADD EMPLOYER' button below to give details of your employment history for at least the last 5 years starting with the most recent. Please detail month and year of each employment and job responsibilities. Add each employer using the button below. Company Name Date Started Date Ended Actions Edit Delete There are no Employers. Add Employer Maximum number of employers reached. Other comments (explain any gaps in employment) Education historyDo you have any qualifications or education?*YesNoEducation HisotryTap 'ADD EDUCATION' button below to give details of your education history for at least the last 5 years starting with the most recent. Please detail month and year of each education with courses and qualifications completed. Add each education history using the button below. Name of educational establishment Actions Edit Delete There are no Educations. Add Education Maximum number of educations reached. Other comments (explain any gaps in education) Tell us about yourselfAttach any CVs or documents you feel may be relevant to this positionSummarise any special training, skills, licenses, certificates, and/or characteristics of yourself that may qualify you as being able to perform your job-related functions for the position for which you are applying.*You may wish to upload a copy of any certificates of above training courses. Drop files here or ReferencesReferencesTap 'ADD REFERENCE' button below to List name, address and telephone number of 3 referees who are able to comment on your honesty, reliability, etc. The referees must not be related to you. Add each reference but using the button below. Reference Type Name Actions Edit Delete There are no References. Add Reference Maximum number of references reached. Legal SectionPlease outline any previous convictions, cautions etc.Have you ever been convicted by the courts or cautioned, reprimanded or given a final warning by the police?(NOTE: The post you have applied for is exempt from the Rehabilitation of Offenders Act 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record needs to be disclosed)*YesNoIf yes, please give details of offences, penalties and datesPlease list any additional information you would like us to consider MedicalDomCare seek to recruit employees on the basis of their general suitability for a position and aims to ensure that consideration of age, sex, marital status, disability and racial or ethnic origin should play no part in this process. Confirmation of appointments is subject to satisfactory medical clearance. Information requested below will be used by our medical advisors solely in order to assess the medical fitness of candidates to carry out the duties of the position. Confidentiality is guaranteed.Height*CMWeight*KGGeneral Practitioner's DetailsGeneral Practitioner's (GP) Name*General Practitioner's (GP) Surgery Address Street Address Address Line 2 City County Post Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands General Practitioner's (GP) Telephone Number*Equality Act 2010The Equality Act 2010 defines a person with having a physical or mental impairment which has a substantial and long-term adverse effect on their normal day-to-day activities.Do you normally enjoy good health?*Prefer not to answerYesNoDo you have a physical or mental impairment that is classed as a disability under the Equality Act 2010?*Prefer not to answerYesNoIf yes, what facilities/adjustments/equipment would assist you in performing your role?Disabilities(please specify)Registered Disabled Number(where relevant)Medical ConditionsHave you ever had any of the following? Epilepsy, fits, blackouts, fainting turns, unexplained loss of conciousness? Vertigo, dizziness, giddiness, problems with balance? Recurrent headache or migrane? Diseases of the nervous system e.g. neuritis, stroke, multiple sclerosis? Angina, heart disease or breathlessness? Raised or low blood pressure? Asthma, bronchitis, emphysema, pneumonia or any other lung disease? Jaundice or any form of hepatitis or other liver problems? Psoriasis, eczema, allergic skin rash or other skin disorder? Anxiety/depression, mental breakdown or stress related problems? Any operations or surgical procedures? Ear trouble or infected ear? Diabetes Kidney trouble or urinary problems? Anxiety, depression or any other mental health condition? Peptic, gastric or duodenal ulcer? Any other serious illness not covered above? None of the above If answered 'Yes', please give detailsIs your eyesight normal? (with glasses/contact lenses)*Prefer not to answerYesNoIs your hearing normal?*Prefer not to answerYesNoAre there any medical reasons why you shouldn't work?*Prefer not to answerYesNoAre you able to carry out strenuous physical activities like bending, lifting and carrying?*Prefer not to answerYesNoPast Medical HistoryHave you ever had to give up a previous job because of an illness?*Prefer not to answerYesNoIf Yes, please give provide brief details.Have you ever been off work continuously within the last five years?*Prefer not to answerYesNoIf Yes, please provide detailsDo you regularly take tablets or medicine?*Prefer not to answerYesNoIf Yes, please provide detailsHas any previous occupation caused you to have an illness?*Prefer not to answerYesNoIf Yes, please provide detailsAre you in receipt of any medical pension or other allowance?*Prefer not to answerYesNoIf Yes, please provide detailsDo you smoke?*Prefer not to answerYesNoIf “yes” how many cigarettes per day?Please enter a number from 0 to 100.Were you immunized against:* Tuberculosis (BCG) Measles German measles Whooping cough Tetanus Polio Hepititss Coronavirus (Covid-19) None of the above Other medical details we should know about Voluntary InformationIn order to monitor the effectiveness of our commitment to equal opportunities it would be helpful if you could complete this section of the form. Completion is not compulsory but should you give details below the information will be used for no other purpose than that as stated in this paragraph.Ethnic OriginAfricanAfro-caribbeanAsian (Chinese / S.E Asia)Asian (Indian Sub Continent)EuropeanPolynesianReferral SourceAdvertisementEmployeeJob CentreBy Walk inBy TelephoneEmployment AgencySearch EngineName of source if applicableReligionBuddhismBahaiChristianityHinduismIslamJainismJudaismNo religionShintoSikhism DeclarationBy accepting the following checkbox I, being the candidate for the before-named appointment, do hereby declare that the particulars entered by me are, to the best of my knowledge and belief, a true and complete record. I understand that the terms of the Contract Employment Act, 1972 (as amended) apply to the post. * I Agree Signature*Please sign in the box with your finger, if you are using a touchscreen device or touch pad, or your mouse, if you are using a computer.Admin NotesPhoneThis field is for validation purposes and should be left unchanged.