Application Form - Elixonn Healthcare Ltd

Application Form

THE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED IN CONFIDENCE.
You must provide the following at interview. Applicants without this documentation may have their application rejected.

1. Two forms of identification (preferably passport and driving licence)

2. An official letter with YOUR name and address on it (eg. Phone Bill/ Bank Statement etc).

3. Proof of ‘Right to Work in the UK’ (if you do not hold an EU passport)

Job Listing Form (#4)

Personal information

Title

First Name

Last Name

Address

Address Line 1

City

Post Code

Email address

Passport Number

Phone/Mobile

Nationality

National Insurance Number

Are you eligible to work in the UK?

Yes

No

Do you hold a full valid UK driving license?

Yes

No

If yes, Do you have any points or convictions etc?

Training Records

Name of Training Provider	Certificate Obtained	Obtained

Please state current Salary Package including benefits & holidays

Rehabilitation of Offenders Act

Have you ever been convicted of a criminal offence?

Yes

No

If yes, please give details / dates of offence(s) and sentence

Have you any prosecutions pending?

Yes

No

Health

Number of days absent in the last 2 years

Are you registered disabled?

Yes

No

If yes please provide your disability number and details:

Education

Start Date

End Date

Name of School

Examinations taken and Qualifications Gained

Want to add another?

Yes

No

Start Date

End Date

Name of School

Examinations taken and Qualifications Gained

Want to add another?

Yes

No

Start Date

End Date

Name of School

Examinations taken and Qualifications Gained

Want to add another?

Yes

No

Start Date

End Date

Name of School

Examinations taken and Qualifications Gained

Want to add another?

Yes

No

Start Date

End Date

Name of School

Examinations taken and Qualifications Gained

Personal Attributes

List your personal attributes

References

Please give the names and addresses of your two most recent employers (if applicable). If you are unable to do this, please clearly outline who your referees are.

Can we contact your current employer before interview?

Yes

No

Reference 1

First Name

Last Name

Their Position (Job title)

Work Relationship

Organisation

Employment Start Date

Employment End Date

Address

Address Line

Post Code

Email

Reference 2

First Name

Last Name

Their Position (Job title)

Work Relationship

Organisation

Employment Start Date

Employment End Date

Address

Address Line

Post Code

Email

Declaration

I confirm that the information provided in this application (and within my Curriculum Vitae if applicable) is both truthful and accurate. I have omitted no facts that could affect my employment. I understand that any false misleading statements could place any subsequent employment in jeopardy.
I understand that any employment entered into is subject to documentary evidence of my right to work in the UK and satisfactory references.
I expressly consent to personal data contained within this form being recorded for the purposes of assessing suitability for the post and may form the basis of any subsequent personnel file.

Elixonn Healthcare Ltd undertakes that it will treat any personal information that you provide to us, or that we obtain from you, in accordance with the requirements of the Data Protection Act 1998.
After initial assessment, Elixonn Healthcare Ltd may keep your details on file pending suitable opportunities that may arise in the future. Please tick if you do not wish us to hold your details

Availability

Please read this before you complete the Availability Form:
Standard working requirements are five days each week plus alternative weekends. It is not a requirement that Care Workers should work more than one period per day but you are free to commit to as many as you would like to. Hours are not guaranteed and shift periods are for illustration only. Payment is made for ‘contact time’ only.

Important: This availability will form the basis of any employment offer, and if you are accepted, forms a commitment on your part.

Total number of hours per week you are seeking

Quick Links

Office Address

Business & Technology Centre
Bessemer Dr.
Stevenage.
SG1 2DX

contactus@elixonnhealthcare.co.uk

Contact us

01438532995
+447470800093

©2022 Elixonn Healthcare Ltd. All Rights Reserved. A Subsidiary of Elixonn Ltd .