Health Professionals
Relatives
Careers

Application Form

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Your application

The completion of this application form is mandatory. If you are offered a position with Cornerstone Healthcare Group, we will use this information to conduct background checks inline with regulations and guidance provided by CQC.

Please complete this application in FULL as we are unable to proceed where answers are in part or not completed. If completing in writing please use capitals. You can use the symbol X instead of a tick if completing online.

Position applied for(Required)

If you have previously applied to, or have been employed by the Company, please give details below:

How did you hear of this position?(Required)

Indeed

Friend or family

Website

Social media

Other (please specify)

How did you hear of this position (other)

About you

First name(Required)

Last name(Required)

Previous names

Current address(Required)

How long have you lived there?(Required)

Telephone number for contact(Required)

Email address(Required)

Do you drive?(Required)

Yes

Do you have any endorsements? (if yes please specify)

Education

1. School/college(Required)

1. Year awarded(Required)

1. Examination level and results(Required)

Education: Add another

Add another

2. School/college

2. Year awarded

2. Examination level and results

Education: Add another 2

Add another

3. School/college

3. Year awarded

3. Examination level and results

Education: Add another 3

Add another

4. School/college

4. Year awarded

4. Examination level and results

Education: Add another 4

Add another

5. School/college

5. Year awarded

5. Examination level and results

Education: Add another 5

Add another

6. Additional space for education

Training / professional qualifications

Any listed will need to have certificate evidence

1. Year awarded

1. Qualification title gained

2. Year awarded

2. Qualification title gained

Your employment history

Current/most recent first. Information must cover the whole of your employment to date. Please state the reasons for any breaks in employment in the section below.

Most recent/current employer name(Required)

Date employed from(Required)

Date employed to(Required)

Job title upon leaving(Required)

Reason for leaving(Required)

Pay rate/salary(Required)

Main duties/responsibilities(Required)

Employer: Add another 1

Add another

2. Employer name(Required)

2. Date employed from(Required)

2. Date employed to(Required)

2. Job title upon leaving(Required)

2. Pay rate/salary(Required)

2. Main duties/responsibilities(Required)

Employer: Add another 2

Add another

3. Employer name(Required)

3. Date employed from(Required)

3. Date employed to(Required)

3. Job title upon leaving(Required)

3. Pay rate/salary(Required)

3. Main duties/responsibilities(Required)

Employer: Add another 3

Add another

4. Employer name(Required)

4. Date employed from(Required)

4. Date employed to(Required)

4. Job title upon leaving(Required)

4. Pay rate/salary(Required)

4. Main duties/responsibilities(Required)

Employer: Add another 4

Add another

5. Employer name(Required)

5. Date employed from(Required)

5. Date employed to(Required)

5. Job title upon leaving(Required)

5. Pay rate/salary(Required)

5. Main duties/responsibilities(Required)

Employer: Add another 5

Add another

6. Employer name(Required)

6. Date employed from(Required)

6. Date employed to(Required)

6. Pay rate/salary(Required)

6. Job title upon leaving(Required)

6. Main duties/responsibilities(Required)

Employer: Add another 6

Add another

7. Employer name(Required)

7. Date employed from(Required)

7. Date employed to(Required)

7. Pay rate/salary(Required)

7. Job title upon leaving(Required)

7. Main duties/responsibilities(Required)

Employer: Add another 7

Add another

8. Employer name(Required)

8. Date employed from(Required)

8. Date employed to(Required)

8. Pay rate/salary(Required)

8. Job title upon leaving(Required)

8. Main duties/responsibilities(Required)

Employer: Add another 8

Add another

9. Employer name(Required)

9. Date employed from(Required)

9. Date employed to(Required)

9. Pay rate/salary(Required)

9. Job title upon leaving(Required)

9. Main duties/responsibilities(Required)

Employer: Add another 9

Add another

Space for additional employment(Required)

Gaps in employment

It is essential to check the continuity of employment, as stated in the application form, and to note and investigate any gaps in employment. Failure to carry through such checks has been identified as a significant factor in several recent abuse cases.

Please use the table below to account for any gaps in employment. The period considered must be the whole working life of the applicant, to date. Please see the appendix if you need to complete any further gaps.

Date gap is from

Date gap is to

Reason for gap

Gap: Add another 1

Add another

2. Date gap is from

2. Date gap is to

2. Reason for gap

Gap: Add another 2

Add another

3. Date gap is from

3. Date gap is to

3. Reason for gap

Your application

Please explain why you have applied for this role and expand on your skills and knowledge to say why you feel you are suited to the position providing details of of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home.

Why you have applied for this role(Required)

Do you require us to make any special arrangements in order for you to participate in the recruitment process?(Required)

Yes

For example, large print forms or additional time to complete forms.

Please provide details...(Required)

Identity details

Nurses: Nursing and Midwifery Council PIN number

Occupational Therapists: HCPC registration number

National Insurance Number(Required)

Eligibility to work in the UK

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?(Required)

Yes

Please provide details...(Required)

If you are successful in the application, would you require a work permit or certificate of sponsorship prior to taking up employment?(Required)

Yes

Note: Minimum age

Please inform the interviewer if you are under the age of 18 years as some positions due to personal care for example have a age limit attached.

References

You must provide references from your two most recent employers. Please provide an additional character referee. 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.

Current or most recent employer name(Required)

Full address(Required)

Tel(Required)

Email(Required)

Job title(Required)

Previous employer name (previous to the one above)(Required)

Full address(Required)

Tel(Required)

Email(Required)

Job title(Required)

Character reference

Please note, this must be someone who has known you 2 or more years, and cannot be a relative/ family member.

Name(Required)

Full address(Required)

Tel(Required)

Email(Required)

Relationship to you(Required)

Length of time known(Required)

Terms and conditions

CRIMINAL RECORD

Workers and employees are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.

You will not be eligible for work in a care setting if you are on the DBS Register(s).

Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.

Consent(Required)

Please check to confirm you have read and agree to the following...

I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.

I understand that I cannot be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise the organisation to request a DBS Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status.