Application for employment
–regulated activity
All information will be treated as strictly confidential, and no approach will be
made to any person without your permission. Please print clearly.
Please return your completed application form to
[email protected].
Position applied for:
If you obtained this position, would you continue in any other employment?
Yes/No
Do we need to make any disability-related adjustments to allow you to take part
in the recruitment process?
Are you entitled to enter or remain in the UK and undertake the work in
question? Yes/No
Personal details
Title: Forename(s):
Surname:
Home address:
Postcode:
Home telephone: Mobile:
Email Address
@ Responsive HealthCare Page 1 01.23
Employment history – Please explain any gaps between employment.
Name & address of Dates Job title Reason for
employer or duties Leaving
Employment 1.
Education and training
School, college, etc. Dates Qualifications
Employment 2.
Employment 3.
Employment 4.
Driving licence, etc.
Current driving licence? Yes/No. If yes, type of licence
Any current endorsements? Yes/No. If yes, give details.
Any motoring prosecutions pending? Yes/No. If yes, give details.
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Please detail any further information you wish to put forward in
support of your application.
Question asked under the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014
Do you have any physical or mental health conditions which are relevant to your
capability, after reasonable adjustments are made, to properly perform the tasks
which are intrinsic to this employment? Yes/No - If Yes, give details:
References I hereby authorise you to contact the references below to obtain
any information which, in your opinion, will attest to my suitability, qualifications
and work history. Tick here [ ]
Work reference: 1 Work reference: 2
Name: Name:
Address: Address:
Post code: Post code:
Telephone: Telephone :
Email: Email:
Privacy notice
We process personal data relating to those who apply for job vacancies with us
or who send speculative job applications to us. We do this for employment
purposes, to assist us in the selection of candidates for employment, and to
assist in the running of the business. The personal data may include identifiers
such as name, date of birth, personal characteristics such as gender,
qualifications and previous employment history.
We will not share any identifiable information about you with third parties
without your consent unless the law allows or requires us to do so. The personal
data provided during an application process will be retained for a period of at
least six months or, if required by law, for as long as is required.
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This privacy notice does not form part of an employment offer or contract
between us. If we make an employment offer to you, we will provide further
information about our handling of your personal information in an employment
context separately.
If you would like to find out more about our data retention policy and how we use
your personal data, you want to see a copy of the information about you that we
hold or have any questions or issues regarding data protection, please email us
with the Subject “Data Protection Request”.
Declaration
The above information is true. I understand that any job offer made on the basis
of untrue or misleading information may be withdrawn or my employment
terminated.
Signed: Date:
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Declaration under the Protection of Freedoms Act 2012
The post for which you are applying is a ‘regulated activity’ within the meaning
of Part 5 Chapter 1 of the Protection of Freedoms Act 2012 and it is a criminal
offence for a ‘barred person’ to apply to work in a regulated activity. If you are
a barred person you must not proceed with this job application.
If your application is successful you will be required to co-operate with us in
obtaining a disclosure of criminal convictions and in checking your barred status
with the Disclosure and Barring Service.
Statement on the recruitment of ex-offenders
Introduction
As an organisation using the Disclosure and Barring Service’s (DBS) checking
service to assess applicants’ suitability for positions of trust, we comply fully with
the Code of Practice and undertake to treat all applicants for positions fairly. We
undertake not to discriminate unfairly against any subject of a DBS check on the
basis of a conviction or other information revealed.
We are committed to the fair treatment of our employees, potential employees
and users of our services, regardless of their offending background.
Policy
We actively promote equality of opportunity for all with the right mix of talent,
skills and potential and welcome applications from a wide range of candidates,
including those with criminal records. We select all candidates for interview
based on their skills, qualifications and experience.
A DBS check is only requested after a thorough risk assessment has indicated
that one is both proportionate and relevant to the position concerned. For those
positions where a DBS check is required, all application forms, job adverts and
recruitment briefs will contain a statement that a DBS check will be requested in
the event of the individual being offered the position.
Where a DBS check is to form part of the recruitment process, we encourage all
applicants called for interview to provide details of their criminal record at an
early stage in the application process. We request that this information is sent
under separate, confidential cover, to a designated person within the
organisation and we guarantee that this information will only be seen by those
who need to see it as part of the recruitment process.
Unless the nature of the position allows us to ask questions about your entire
criminal record, we only ask about ‘unspent’ convictions as defined in the
Rehabilitation of Offenders Act 1974.
We ensure that all those who are involved in the recruitment process have been
suitably trained to identify and assess the relevance and circumstances of
offences. We also ensure that they have received appropriate guidance and
training in the relevant legislation relating to the employment of ex-offenders,
e.g. the Rehabilitation of Offenders Act 1974, and in the secure handling of
“sensitive personal data”, e.g. DBS checks.
At interview, or in a separate discussion, we ensure that an open and measured
discussion takes place on the subject of any offences or other matter that might
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be relevant to the position. Failure to reveal information that is directly relevant
to the position sought could lead to withdrawal of an offer of employment.
This policy document is made available to all DBS applicants at the outset of the
recruitment process and we make every subject of a DBS check aware of the
existence of the Code of Practice and make a copy available on request.
We undertake to discuss any matter revealed in a DBS check with the person
seeking the position before withdrawing a conditional offer of employment.
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