Local Registration - AG Care Services Ltd

Registration Form (UK Residents)

Step 1 of 11 - Personal Details

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Date of Application

Post Applied for:(Required)

Personal Details

THE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED IN CONFIDENCE.

Last Name(Required)

First Name(Required)

Address(Required)

Street Address Address Line 2 City County Postcode

National Insurance Number(Required)

Home Telephone Number(Required)

Daytime Telephone Number(Required)

Mobile Phone Number(Required)

Email Address(Required)

Are you eligible to work in the UK?(Required)

Yes

Do you hold a full UK driving license?(Required)

Yes

Do you have access to your own vehicle?(Required)

Yes

If you are successful you will be required to provide relevant evidence of the above details prior to your appointment.

Present Employment

Present Employment (If unemployed give details of last employer)

Name of Employer(Required)

Address(Required)

Street Address Address Line 2 City County Postcode

Post Title(Required)

Department / Section:(Required)

Brief description of duties:(Required)

Reason for leaving (if no longer employed):(Required)

Previous Employment

Previous Employment (most recent employer first). Please cover the last 5 years and state the nature of business - if not public sector

Previous employment

Name of Employer:

Address:

Position Held:

Summary of duties:

Reason for leaving:

Education

Qualifications obtained from Schools, Colleges and Universities.

Please list highest qualification first:(Required)

College or University

Course

Qualifications & Grades Obtained

Professional, Technical or Management Qualifications

Please give details:

Professional/Technical/ Management Qualifications

Professional/Technical/ Management Qualifications:

Course Details:

Membership of any Professional / Technical Associations- Please state level of Membership:

Training and Development

Please give details of any training and development courses or non-qualifications courses which support your application. Include any on the job training as well as formal courses.

Training Programmes or Courses:

Title of Training Programme or Course

Duration of Course

Rehabilitation of Offenders Act (1974)

Do you have any convictions that are unspent under the rehabilitation of offenders act 1974?(Required)

Yes

Please give details / dates of offence(s) and sentence:

Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this post(Required)

Yes

Please give details / dates of offence(s) and sentence:

Protecting Children and Vulnerable Adults

A criminal records background check is legally required for all candidates applying for roles that will put them in conduct with vulnerable clients.

Do you have a current Disclosure and Barring Service certificate?(Required)

Yes

Current DBS certificate Number :

Are you subscribed to the online update service?(Required)

Yes

Please attach a copy of your current DBS Certificate

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, docx, Max. file size: 10 MB.

Disability Discrimination Act

Do you have a disability which is relevant to your application?

Yes

If yes, please give details:

We are committed to equal opportunities

Do we need to make any specific arrangements in order for you to attend the interview?

Yes

If yes, please give details:

References

Please give the names and addresses of your two most recent professional referees. References will be sent electronically where possible to help expedite your application. Please ensure your referees are aware and expecting your reference request.

Reference 1

Name(Required)

Position (Job Title)(Required)

Work Relationship(Required)

Organisation(Required)

Telephone Number(Required)

Email(Required)

Address

Street Address Address Line 2 City County ZIP / Postal Code Country

Are you willing for this referee to be approached prior to the interview?(Required)

Yes

Reference 2

Name(Required)

Position (Job Title)(Required)

Organisation(Required)

Work Relationship(Required)

Email(Required)

Telephone Number(Required)

Address

Street Address Address Line 2 City County ZIP / Postal Code Country

Are you willing for this referee to be approached prior to the interview?(Required)

Yes

Declaration

By clicking the submit button to this application form, I certify that:

all the information given by me on this form is correct to the best of my knowledge
all questions relating to me have been accurately and fully answered
I possess all the qualifications which I claim to hold
I have read and, if appointed, am prepared to accept the conditions set out in the conditions of employment and the job description.

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Registration Form (UK Residents)

Personal Details

Present Employment

Previous Employment

Education

Professional, Technical or Management Qualifications

Training and Development

Rehabilitation of Offenders Act (1974)

Protecting Children and Vulnerable Adults

Disability Discrimination Act

We are committed to equal opportunities

References

Reference 1

Reference 2

Recruitment Monitoring

Payment Details

Declaration

By clicking the submit button to this application form, I certify that:

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