Position applied for:
Approx. hours wanted:
Please indicate which area you would prefer to work in:
How did you find out about this job:
Name in Full:
Current Address:
Date moved to this address:
Mobile Phone:
Home Phone:
Previous Address:
Date that you moved here
Own Transport:
Current Clean Driving Licence:
Do you have any endorsements on your licence?
Do you have a current DBS check:
Are you on the DBS Update service?
If you have answered YES, please provide your Update Number:
Please give the date of when your last DBS check was carried out:
Next of Kin Full Name:
Next of Kin Address:
Next of Kin Phone:
Are there any restrictions to your status here in the UK that may affect your right to take up employment here:
If YES, please provide details:

EMPLOYMENT HISTORY - Current, most recent first. Going back 10 years. Any breaks in employment can be explained at interview, should you be successful.

Name of your most recent / last employer:
Your Job Title
Contact Phone number:
Name of your employer prior to the one above:
Position Held
Address of your employer prior to the one above:
Contact number:
Name of your employer previous to the one above::
Post Held
Address of your employer previous to this one::


Please give details of any training courses you have completed relevant to this post applied for:


Do you have any Mental, Physical Disability or Illness (previously, currently or recurring) which is relevant to the post for which you are applying?
If YES, Please give details:
Have you ever had or currently have any back or neck injuries?
If YES, please give details:
Do you suffer from Dermatitis?
Are you allergic to latex?
Please give details of any time you have taken off work over the last 12 months due to illness:
Name of your GP::
Address of your GP:
GP Phone Number:
In your opinion, are you mentally and physically able to safely carry out all duties as described in your job description.
Do you understand that if any of your circumstances change you must inform the Registered Manager of the branch you work for:


As part of our ongoing support for you, you are required to attend Supervision on atleast a 3 monthly basis or as and when required. Are you happy to attend these sessions?


You have the option to opt out of the 48 hour working week limitation, as laid down in the Working Time Regulations 1998. Do YOU wish to opt out?


Coastal Homecare will hold and retain relevant personal information about you as is required by legislation. All records will be held in compliance with the principles of the Data Protection Act 1998. Do you consent for this information to be used by Coastal Homecare internally and to external bodies working with us in employment administration?


If your application is successful and you are given the opportunity for an interview, you will be asked to complete a DBS (Criminal Records Check) form. DO YOU HAVE ANY CRIMINAL CONVICTIONS, whether spent or not? Charges that were proceeded with or not or any warnings and cautions?
If you have answered YES to the above question please give details:


DO YOU DECLARE that to the best of your knowledge and belief the information you have given in this application is TRUE and you understand that this information forms the basis of your contract of employment. If any of the information you have supplied to us is found to be falsely declared, your contract may have been fundamentally breached and your employment may be terminated immediately:


You must provide references from your two most recent employers.

Please provide an additional character referee. All will be contacted.

If you are unable to provide the required references, please discuss with us.

Please provide the full name of your 1st referee. This should be your current or most recent employer:
1st referee address Address:
1st referee Phone:
1st referee E-mail:
2nd Referee Full Name: This should be the previous employer to the one above.
2nd referee Address:
2nd referee Phone:
2nd referee E-mail:
3rd Referee Name: This does not need to be an employer, but someone who can vouch for your character. It can not be a family member.
3rd Referee Address:
3rd Referee Phone:
3rd Referee E-mail: