A kind, compassionate and effective domiciliary care

Do you have a current Full UK Driving Licence? Yes/No

If Yes, do you have the use of a car for work purposes? Yes/No

Do you have any endorsements on your licence? Yes/No

Prepared to work: FULL-TIME? Yes/No

Prepared to work: PART-TIME? Yes/No (if YES please indicate preferred hours)

Prepared to work: SHIFTS? Yes/No

Do you have any other work commitments? Yes/No

Please provide details of any outstanding holidays to be taken

WHEN ARE YOU AVAILABLE TO TAKE UP EMPLOYMENT?

Have you any convictions which are not regarded as “spent” Under the Rehabilitation of Offenders Act 1974? Yes/No (If “yes”, describe the offence and date of conviction)

Are you currently the subject of any criminal proceedings or convictions? Yes/No (If Yes, please state)

• I have read and understood the information supplied to me in relation to this Job Position, and the information requested in
  this Job Application Form. I confirm that all information supplied by me is true and correct to the best of my beliefs.

• I give consent for a third party, to view my employment file for compliance or inspection purposes

• I authorise Amflo Care Services Ltd, to pay my wages, directly into my bank account, details of which I have given on this
  form

• I give the prospective employer the right to follow up all references, and to make any other job-related enquiries as may be
  deemed necessary.

Equality and Diversity Monitoring Form

Please tick the box alongside the category that you feel best describes your ethnic origin, using the classification below

The Equality Act 2010, provides for disabled people to have a legal right to fair treatment in employment matters. When answering this question please note that the Equality Act 2010 defines a disability as “a mental or physical impairment which has a substantial and long-term adverse effect upon a person’s ability to carry out normal day-to-day activities”.

Confidential Medical Declaration

Do you have, or have you ever suffered from, the following:

Confidentiality and Data Protection

Upload your CV

Upload your IELTS English Test

TB Test Result

Upload your Police Clearance Result

Upload your ID (Passport)

Upload your Driving Licence

I agreed to abide by the following clauses:

• I will maintain the confidentiality of all the service user records and any other information that involves their care / medical management of the patient.

• I shall not disclose service user information in any manner that causes any harm to the service user or the relatives of the service user in any manner.

• I shall keep all medical history records / information which include papers, images, and reports of the patient in a confidential manner.

• I shall maintain confidentiality with regard to the verbal discussion and observation about the patient.

• I shall withhold all personal information of the patient such as social security number, telephone number, mailing address, spouse details, key safe code etc.

• I understand that unauthorized release of patient information to those who need not know it will make me liable for legal prosecution and disciplinary action by my employer as well.

Declaration

By putiing my name (signing) below, I acknowledge to have read and understood all the clauses specified above and signify my compliance to all the clauses specified herein above. In the event of violation of any of the clauses specified above the patient has the right to take appropriate action against me.