Rehab Application Form -

- Step 1 of 11

Title *

Full Name *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

From (Home Address) *

To (Home Address)

Previous Address

(Please ensure the past 5 years is covered)

Number of Address held in last 5 years

Previous Address 1

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

From (Address 1)

To (Address 1)

Previous Address 2

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

From (Address 2)

To (Address 2)

Previous Address 3

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

From (Address 3)

To (Address 3)

Previous Address 4

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

From (Address 4)

To (Address 4)

Previous Address 5

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

From (Address 5)

To (Address 5)

Date of Birth *

Mobile Phone *

Home Telephone

Mother's Maiden Name

Do you hold a valid driving license? *

Have you been vaccinated against COVID-19? *

Date 1 *

Date 2 *

Next of Kin

Full Name

Relationship

Phone

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Equal Opportunities

Country of birth *

What languages do you speak?

Marital status *

Single
Married
Widowed
Divorced

Please indicate your ethnic group by circling the appropriate category

White
Black – African
Black – Caribbean
Black – Other (please specify)
Bangladeshi
Chinese
Indian
Pakistani
Other (please specify)

Please specify

Gender

Male
Female
Other

Neither I identify as

Work Eligibility

Nationality *

Are you legally eligible for employment in the UK? *

Do you have any endorsements in your passport which limit your stay or length of Employment in the UK? *

Do you require a work permit? *

Current/Last employment details

Name of current/last employer *

Address of current/last employer *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Type of business

Job title *

Employment dates *

Employment dates To *

Salary (including any bonuses)

Notice period *

Reason for leaving

Manager's name *

Position *

Previous Employment History 1

Please provide details of all previous employment held, starting with the most recent and including details of gaps in employment.

Name of employer

Address of employer

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Department

Position

Employment dates

Employment dates To

Reason for leaving

Previous Employment History 2

Please provide details of all previous employment held, starting with the most recent and including details of gaps in employment.

Name of employer

Address of employer

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Department

Position

Employment dates

Employment dates To

Reason for leaving

Previous Employment History 3

Please provide details of all previous employment held, starting with the most recent and including details of gaps in employment.

Name of employer

Address of employer

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Department

Position

Employment dates

Employment dates To

Reason for leaving

Previous Employment History 4

Please provide details of all previous employment held, starting with the most recent and including details of gaps in employment.

Name of employer

Address of employer

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Department

Position

Employment dates

Employment dates To

Reason for leaving

Details of gaps of employment

Working Time Directive: Opt-Out Agreement

I choose to opt-out of the Working Time Directive which means I can work more than 48 hours per week if I wish to do so Please tick as appropriate *

AGREE
DISAGREE

Date *

Qualifications

(start with most recent)

Number of Qualifications *

Professional qualification / Training course 1 *

Date *

Place obtained *

Professional qualification / Training course 2 *

Date *

Place obtained *

Professional qualification / Training course 3 *

Date *

Place obtained *

Professional qualification / Training course 4 *

Date *

Place obtained *

Professional qualification / Training course 5 *

Date *

Place obtained *

References

Please provide detail of two people (no relatives) who can provide us with references. They must have a professional qualification and or hold a senior position within the field of care and be able to comment on your ability and work experience. One must be your current or most recent employer.

Reference 1

Name *

Job title *

Company Name *

Company Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Email *

Can we contact this referee immediately?

Reference 2

Name *

Job title *

Company Name *

Company Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Email *

Can we contact this referee immediately?

HEALTH QUESTIONNAIRE

Name *

Date *

Position Offered *

If the answer is yes to any of the questions on this form, please give full details in the space provided of the dates, duration and outcome of illness or condition. If we have any concerns about your fitness for work, employment will be subject to satisfactory medicalreports. (Additional Information to “yes” response)

Tuberculosis, asthma, bronchitis or chest problems? *