Employment Application Form

Safer Recruitment, Right to Work, Enhanced DBS and Address History Declaration

CQC safer recruitment evidence for regulated care services. William T Healthcare completes role-specific checks and follows current DBS/CQC guidance. Fields marked * are required.

1. Position Applied For

Employment type

2. Personal Details
3. Right to Work in the UK
Are you legally allowed to work in the UK? *
Are there any visa restrictions on your work?
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
4. Enhanced DBS, Barred List and Safeguarding Consent

You must provide all names used and a continuous address history for at least the last 5 years. Overseas addresses must be included.

Do you consent to the organisation applying for an enhanced DBS check as part of safeguarding and safer recruitment? *
Do you understand the role may require barred list checks where legally eligible?
Are you subscribed to the DBS Update Service?
If yes, do you consent to the employer checking your DBS Update Service status?
Have you ever been barred from working with adults or children?
Do you have any relevant convictions, cautions or other matters to disclose under DBS rules?
If yes to any disclosure question, provide details on a confidential separate sheet.
5. Address History — Last 5 Years Minimum, No Gaps
From MM/YYYY To MM/YYYY Full address including postcode OR overseas address Town/City Country Reason/notes

If you have lived overseas, write the country and full overseas address where possible. If no fixed abode, refuge, student accommodation, armed forces, vessel or other unusual address applies, explain in the notes column.

6. Employment History — Full History and Gaps
From MM/YYYY To MM/YYYY Employer / organisation Job title Reason for leaving Reference now?

Include paid work, agency work, voluntary work, caring responsibilities, study, unemployment and overseas employment. Explain all gaps below.

7. Employment Gaps / Career Breaks
From MM/YYYY To MM/YYYY Reason for gap Evidence available, if any
8. Education, Qualifications and Training
Dates School/college/provider Qualification/course Result/grade Certificate seen
9. Care / Healthcare Training Completed
Course Provider Date completed Expiry/renewal date Evidence checked
10. Professional Registration / Memberships
Body / register Registration number Expiry date Restrictions/conditions? Checked by employer
11. Skills, Experience and Care Suitability
Have you worked in health or social care before?
Are you comfortable supporting personal care respectfully and safely?
Can you safely lift/support/transfer individuals where trained and risk-assessed?
Are you comfortable administering/supporting medication only when trained, assessed and authorised?
Are you comfortable working flexible hours, including weekends and bank holidays?
Have you applied to or worked for this organisation before?
Do you require reasonable adjustments for interview, onboarding or work?
12. Driving and Travel
Do you hold a current driving licence?
Licence type
Do you have any restrictions, points or endorsements?
Do you have reliable transport to attend work locations on time?
Are you willing to use your vehicle for work if required and insured appropriately?
13. Professional Competency & Workplace Behaviour
Statement Strongly Agree Agree Neutral Disagree Strongly Disagree
I handle pressure well in fast-paced settings
I communicate effectively with people receiving care, families and professionals
I show empathy, dignity and respect in care interactions
I adapt quickly to new procedures and care plans
I follow health, safety, infection prevention and safeguarding procedures
I accept feedback and use supervision to improve practice
I understand confidentiality and professional boundaries

14. Scenario-Based Questions

15. Schedule Availability

Write earliest start time and latest finish time. Add restrictions such as childcare, transport, study, religious/cultural commitments or other availability limits.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Earliest start
Latest finish
Unavailable / restrictions
16. References
Referee name Organisation / relationship Job title Email Telephone Can contact now?

References should normally include your current/most recent employer and a relevant care-sector employer where applicable. Family members should not normally be used as referees.

17. Equality, Inclusion and Optional Support

This section is kept separate from shortlisting where possible. It is used to support fair recruitment and reasonable adjustments, not to discriminate.

18. Applicant Declaration

Download a PDF copy for your own records at any time. Submitting sends your application securely to William T Healthcare.