Personal Details
First Names: Ephraim Address:
30 Schooner Avenue
Newport
Surname: Chinungu
Maiden Name: N/A
Previous Names: N/A
Marital Status: Married
Gender: Male Postcode: NP10 8EY
Place of Birth: Harare, Zimbabwe Nationality: Zimbabwean
Telephone Number: NI Number:
Are you a Driver: Yes Own Transport Yes
How long have you had a 27+ years
Any Endorsements: No
licence?
Are you a United Kingdom (UK), European Community (EC), European Economic No*
Area (EEA) National
*If no, please detail your current immigration status and the relevant visa currently held (including Visa number)
Limited Leave To Remain
Are you related to any of our current members of staff or Service Users? Yes
Equality Act 2010 - Under the Equality Act 2010, the definition of disability is if you have a physical or mental
impairment that has a “substantial” and “long-term adverse effect” on your ability to carry out normal day-to-day
activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-
under-equality-act- 2010.
For the purposes of this application and interview stage only, is there anything you
N/A
would like us to be aware of so that we can make reasonable adjustments during the
process?
Education *(All qualifications will be subject to a satisfactory check).
School / College / University Date From: Date To: Examinations,
Qualifications*
Harare High School, Zimbabwe Jan 1986 Nov 1991 GSCEs O and A Levels
Explanation of Gaps Use this section to detail any gaps in employment and why
Training Courses attended or completing (evidence of attending courses is required)
Subject Location Date Details
N/A
Professional Memberships / Registrations
Registration
Name of Organisation Renewal Date Details
Number
N/A
Employment History
Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be
explained. Use a separate attached sheet if required; please sign the sheet(s)
Current / Most recent employer
October 2020 Dec 2021 £18/hr
Start Date: End Date: Salary:
Support Worker Elysium Healthcare
Job Role: Employer Name:
Personal
Reason for Leaving: Contact Name:
Duties: Address:
Male and Female Medium And Low Secure Mental Wellesley Hospital
Specialist Health Services Elysium, Westpatk 26
Chelston, Wellington
TA21 9FF
Postcode:
01823 668150
Telephone:
Email:
Employment History
Start Date: July 2017 End Date: July 2022 Salary: Job Rate
Accountant Cara Caring Services
Job Role: Employer Name:
Company Changed Hands and Eoghan Mortell
Reason for Leaving: Brought In Their Own Accountant Contact Name:
Address:
34 Godfrey Road
Newport
Duties:
NP20 4PE
Postcode:
Telephone:
Email:
Employment History Continued (Copy this page if required)
End Date: Salary:
Employer Name:
Contact Name:
Address:
Duties:
Postcode:
Telephone:
Email:
End Date: Salary:
Employer Name:
Contact Name:
Address:
Duties:
Postcode:
Telephone:
Email:
Employment History Continued (Copy this page if required)
Start Date: End Date: Salary:
Job Role: Employer Name:
Reason for Leaving: Contact Name:
Address:
Duties:
Postcode:
Telephone:
Email:
Start Date: End Date: Salary:
Job Role: Employer Name:
Reason for Leaving: Contact Name:
Address:
Duties:
Postcode:
Telephone:
Email:
References: Please provide names, addresses and telephone numbers for referees below who we may approach for
a reference.
You must provide references from your two most recent employers. In line with CQC requirements, we require
references covering your last five years employment. If you have not had more than one employer in the last five
years, we require a further reference. Please provide two character references if you are unable to obtain two
professional references, e.g. in the case of an applicant who has been raising children for ten years. All will be
contacted, therefore, please inform the referees of the fact that you have used their name. If you are unable to provide
the required references, please discuss the matter with us.
Referee One Referee Two
Contact Name: James Mubvereki Eoghan Mortell
Business Name: Elysium Healthcare Cara Caring Ltd
Wellesley Hospital 34 GodfreyRoad
Elysium Newport
Address: Westpark 26 Gwent
Chelston
Postcode: TA21 9FF NP20 4PE
Telephone: 01823 668150 0797755516
Capacity in which known Manager Director
Referee Three Referee Four
Contact Name:
Business Name:
Address:
Postcode:
Telephone:
Email:
Capacity in which known
Additional Referee Additional
Referee
Contact Name:
Address:
Postcode:
Telephone:
Email:
Professional / Character:
Capacity in which known
Safeguarding / Ex-Offenders Declaration: Please note this section will only be seen by those involved in the
recruitment process and will be treated with the strictest confidence.
The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all
applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual
orientation, pregnancy or maternity and marriage or civil partnership. Nurseline Community Services undertakes
not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.
Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the
relevance of the information you provide in respect of the nature of the position and the particular circumstances.
Are you currently bound over or do you have any current UNSPENT convictions No
that have been issued by a Court or Court-Martial in the United Kingdom or in any
other country?
Do you have any current UNSPENT police cautions, reprimands or final warnings
No
in the United Kingdom or in any other country?
We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this
application form, you consent to holding the information contained within this application form. If successfully shortlisted, data
will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot
estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for
which we are considering you). When that period is over, we will either delete your data or inform you that we would like to keep
it in our database for future roles.
We have privacy policies that you can request for further information. Please be assured that your data will be securely stored
by the Registered Manager and only used for the purposes of recruiting for this vacant post.
You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept
informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please
contact the Registered Manager to discuss.
Declaration
The information in this application form is true and complete. I agree that any deliberate omission,
falsification or misrepresentation in the application form will be grounds for rejecting this application or
subsequent dismissal if employed. Where applicable, I consent that can seek clarification regarding
professional registration details.
Ephraim Chinungu
Print Full Name:
E.Chinungu 07/09/2022
Signature: Date:
Supporting Statement
Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would
also be of value to describe particular strengths and talents that set you apart from others as well as including skills gained from
work, home and other activities This should be completed before attending any interview. It will be discussed as part of the interview
process.
If I was a Service User, I would like:
-To be treated with respect and dignity
-To be taken as part of the wider community without any prejudice
-To be given my independence
I believe that the Service User’s family and Relatives would like the following:
That the Service User should be treated with due respect and dignity as a human being as a human being and to be embraced as part of the wider
community.
I believe that I can support a Service User because:
I have the experience to deal with them.
I am sympathetic and empathetic and would like to give them the independence to express themselves.
As a member of the team, I would feel valued when:
My contribution and team effort are recognized and my suggestions and ideas are taken into consideration when looking for solutions and in
decision making.
I believe that a good relationship between me and the Service User depends upon:
Knowing the weakness and vulnerability of the Service User and embracing it to create an atmosphere that can thrive for the Service User,
I believe that I learn best when: I believe that a good working team is
made by:
I humble myself and embrace new ideas and concepts. Putting your personal ego last and work towards unity, team
building and goal congruency.
I believe that my role in relation to the Service User is:
To provide the care, protection support and a conducive environment for them to express themselves and allowing them to be theirselves.
My other beliefs and values relevant to my job role are:
That as a human race we are all equal and the same despite the differences in race, color, social creed and intelligence quotient. If we work
towards removing the barriers and smokescreens of hate and divisiveness that we encounter on a daily basis we will have a better and inclusive
world for everyone.
