Application Form Title * Mr Mrs Miss Ms Other Name * First Name Last Name Date Of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Number * Telephone Number Email Address * National Insurance Number * Next Of Kin: Name Next Of Kin: Relationship Next Of Kin: Contact Number Which Area Are You Applying For? * Blackpool and the Fylde Coast Preston Have you ever worked in the care sector before? Identification Please provide details on your ID. You need at least 3 forms of ID. You must have at least one of: driving license, passport or original birth certificate. You must also have 2 forms of ID confirming your name and address. If you are unable to provide suitable ID, you will not be offered employment. Identification: Driving License Number Identification: Driving License Issue Date Identification: Birth Certificate Number (Issued At Birth) Identification: Birth Certificate Issue Date Identification: Passport Number Identification: Passport Issue Date Identification: Other Government Issued Document 1: Birth Certificate 6 Weeks After Birth Marriage/Civil Partnership Certificate Gas/Electric/Water Bill Statement Mortgage Statement Bank/Building Society Statement Credit Card Statement Financial Statement (Pension, ISA,etc.) P45/P60 Statement Benefit Statement Identification: Other Government Issued Document 2 Birth Certificate 6 Weeks After Birth Marriage/Civil Partnership Certificate Gas/Electric/Water Bill Statement Mortgage Statement Bank/Building Society Statement Credit Card Statement Financial Statement (Pension, ISA,etc.) P45/P60 Statement Benefit Statement DBS Please provide your DBS information. If you do not have an online checkable DBS then please be aware you will need to purchase one before you can begin working with the company. DBS' need to be put on the Update Service within 28 days of the certificate issue date. Have you got an Online Checkable DBS - is it on the Update Service? * Yes No I'm waiting for it to arrive What is your DBS number? What is the surname on the certificate? Convictions, Cautions and Criminal Proceedings It is important that you disclose any convictions or cautions below, as failure to do so may result in your employment offer being rescinded should your DBS come back negative Do You Have Any Convictions Or Cautions? * Yes No If Yes, Please Supply Date, Nature Of Conviction/Caution/Charge, Allegations/Investigations, Court And Result: Are You Currently the Subject of Any Criminal Proceedings Or Any Police Investigations? * Yes No If Yes, Please Supply Date, Nature Of Conviction/Caution/Charge, Allegations/Investigations, Court And Result What Areas Of Work Are You Interested In? Learning Disability Mental Health Challenging Behaviour Complex Care End Of Life Dementia Areas of Work: Other What Training Courses Have You Done (And Are In Date)? Manual Handling First Aid Food Hygiene Safeguarding Infection Control Please Detail Any Other Certificates Or Qualifications Below: References Please provide references for your past 7 years of work. If you have any gaps in your employment, please detail them in the "Employment Gaps" section, including how you supported yourself financially during that period. Reference 1: Name Of Employer - This Must Be Your Current/Most Recent Employer Reference 1: Start And End Date Reference 1: Contact Details Reference 2: Name Of Employer Reference 2: Start And End Date Reference 2: Contact Details Reference 3: Name Of Employer Reference 3: Start And End Date Reference 3: Contact Details Reference 4: Name Of Employer Reference 4: Start And End Date Reference 4: Contact Details Additional References - Work History Must Go Back Five Years Employment Gaps Character References Please provide character references if you do not have a full 5 years job history OR less than 3 employment references. The character reference must NOT be a family member or friend. It could be someone who is a professional (GP, lawyer etc) or that you have worked with in the past (not a manager). Character Reference 1: Name Of Character Reference Character Reference 1: How Long You Have Known Them Character Reference 1: Contact Details Character Reference 2: Name of Character Reference Character Reference 2: How Long You Have Known Them Character Reference 2: Contact Details Additional Character References How Did You Hear About Us? * Indeed, Facebook, a current staff member (please name), etc Availability Please select all the shifts below that you can do on a week-to-week basis. The company asks that you can also work alternate weekends Please Select Your Availablity Monday Morning Shift (08:00 - 12:00) Monday Lunch Shift (12:00 - 16:00) Monday Tea Shift (16:00 - 19:00) Monday Bed Shift (19:00 - 22:00) Monday Night Shift (22:00 - 07:00) Tuesday Morning Shift (08:00 - 12:00) Tuesday Lunch Shift (12:00 - 16:00) Tuesday Tea Shift (16:00 - 19:00) Tuesday Bed Shift (19:00 - 22:00) Tuesday Night Shift (22:00 - 07:00) Wednesday Morning Shift (08:00 - 12:00) Wednesday Lunch Shift (12:00 - 16:00) Wednesday Tea Shift (16:00 - 19:00) Wednesday Bed Shift (19:00 - 22:00) Wednesday Night Shift (22:00 - 07:00) Thursday Morning Shift (08:00 - 12:00) Thursday Lunch Shift (12:00 - 16:00) Thursday Tea Shift (16:00 - 19:00) Thursday Bed Shift (19:00 - 22:00) Thursday Night Shift (22:00 - 07:00) Friday Morning Shift (08:00 - 12:00) Friday Lunch Shift (12:00 - 16:00) Friday Tea Shift (16:00 - 19:00) Friday Bed Shift (19:00 - 22:00) Friday Night Shift (22:00 - 07:00) Saturday Morning Shift (08:00 - 12:00) Saturday Lunch Shift (12:00 - 16:00) Saturday Tea Shift (16:00 - 19:00) Saturday Bed Shift (19:00 - 22:00) Saturday Night Shift (22:00 - 07:00) Sunday Morning Shift (08:00 - 12:00) Sunday Lunch Shift (12:00 - 16:00) Sunday Tea Shift (16:00 - 19:00) Sunday Bed Shift (19:00 - 22:00) Sunday Night Shift (22:00 - 07:00) Equal Opportunities The information gathered below is used to assist us in monitoring the implementation and effectiveness of our Equal Opportunities policy. What Is Your Ethnicity? What Is Your Gender? What Is Your Sexual Orientation? What Is Your Religious Affiliation? Do You Consider Yourself To Have A Disability Or Long-Term Health Condition? Application Submission By submitting the application form, you agree that the above information is correct to the best of your knowledge. Unsuccessful applications will be immediately deleted and no information will continue to be held. COVID Vaccine The information below is to determine whether you have or have not had the vaccine. If not already recievied, you will Have You Had The COVID-19 Vaccine? * Yes No If No, Would You Be Willing To Get The Vaccine Once It's Made Available To You? Yes No Are You Medically Exempt From Receiving The Vaccine? * Yes No Thank you for submitting your application for employment with Baxter Life Care! Someone will be in contact shortly to discuss the outcome of your application. Unsuccessful applications will be deleted.