QCM Job Application Form

Step 1Role & Personal

Step 2Education & Training

Step 3Employment History

Step 4References

Step 5Declarations & Values

Step 1 of 5

Please ensure that you complete the application form in full as we cannot accept CVs. Please complete with black ink and block capitals. This form will be kept in confidence. Please note that no applicant will be unfairly discriminated against. This includes discrimination on account of age, cultural, religious, political beliefs, disability, ethnicity, gender, race, relationship status, sexual orientation, and / or Trade Union membership or stewardship. If you have any special requirements to support you to complete this form (e.g. the need for large print or additional time), please contact the Registered Manager.

Role Preferences

Tell us about your preferred working pattern and availability.

Work Preference

Hours Requested

I understand this role may include: Shift work, Unsociable Hours, Lone working involved. *

Shift Preferences (select all that apply)

Day	Day Shift	Night Shift	Either
Monday	Monday Day Shift	Monday Night Shift	Monday Either
Tuesday	Tuesday Day Shift	Tuesday Night Shift	Tuesday Either
Wednesday	Wednesday Day Shift	Wednesday Night Shift	Wednesday Either
Thursday	Thursday Day Shift	Thursday Night Shift	Thursday Either
Friday	Friday Day Shift	Friday Night Shift	Friday Either
Saturday	Saturday Day Shift	Saturday Night Shift	Saturday Either
Sunday	Sunday Day Shift	Sunday Night Shift	Sunday Either

Role Details

Position Applied For *

Location (not applicable to sponsored staff)

Personal Details

Title *

First Name *

Middle Name *

Last Name *

Previous Names or Maiden Name

Gender *

NI Number *

Postcode *

Email Address *

Phone Number *

Residential Address History (Last 5 Years)

Provide every address for the last five years with no gaps. Add additional addresses if required.

Current Address *

Address Line 1 *

Address Line 2

City *

County/State *

Postal Code *

Date moved in *

Date moved out

Currently living here

Equality & Adjustments

Equality Act 2010 - Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a "substantial" and "long-term adverse effect" on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-under-equality-act-2010

For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process? *

Not applicable to me

I have special need (state below)

Please specify your requirements *

Education

All qualifications will be subject to a satisfactory check.

Highest Education Attained

High School (Secondary School)

Date from

Date Graduated

Qualification/Certificate Obtained

Higher Education 1 (University/College)

Higher Institution (University/College)

Date from

Date Graduated

Qualification/Certificate Obtained

Special Trainings

List any Training Courses attended or completed (evidence of attendance or completion would be required)

Employment History

Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained.

Current/Most recent employer *

Job Role *

Start Date *

End Date

I currently work here

Employer's Address

Duties performed

Reason for Leaving *

Previous employer 1

Previous employer

Job Role

Start Date

End Date

Employer's Address

Duties performed

Reason for Leaving

Provide details of previous employment not captured above. Include start and end dates.

References

Please provide names, addresses and telephone numbers for referees below whom we may approach for a reference. In line with CQC requirements, we require references (or other satisfactory evidence as the employer may determine) from all previous employers concerned with the provision of services relating to health or social care, or children or vulnerable adults which should include details of why their employment came to an end (note that this is not time limited). If your previous employment does not concern the provision of services relating to health or social care, or children or vulnerable adults, you must provide references from your two most recent employers. Please provide one character reference if you are unable to obtain two professional references, e.g. in the case of an applicant who has been raising children for ten years. 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.

Professional Reference 1

Email should be official email address

Name *

Last Name *

Business Name *

Email *

Phone Number

Capacity in which known

Address

Professional Reference 2

Email should be official email address

Name *

Last Name *

Business Name *

Email *

Phone Number

Capacity in which known

Address

Professional Reference 3

Email should be official email address

Name

Last Name

Business Name

Phone Number

Capacity in which known

Address

Character Reference 1

Name *

Last Name *

Email *

Phone Number *

Capacity in which known

Safeguarding/Ex-Offenders Declaration

Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest confidentiality.

The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. QCM Healthcare undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country? *

Yes

Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country? *

Yes

Privacy Statement

We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to us holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you). When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles. We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the CQC Registered Manager and only used for the purposes of recruiting for this vacant post. You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the CQC Registered Manager to discuss.

Declaration

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that can seek clarification regarding professional registration details.

Name *

Last Name *

Signature *

Draw your signature using your mouse or finger, then click "Use Signature".

Date *

Supporting Statement

Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe particular strengths and talents that set you apart from others as well as including skills gained from work, home and other activities.

Values Based Screening Questions

Application Form Values Based Screening Questions. This should be completed before attending any interview. It will be discussed as part of the interview process. If I was a Service User, I would like:

If I was a Service User I would like: *

I believe that the Service Users family and Relatives would like the following: *

I believe that I can support a Service User because: *

As a member of the team I would feel valued when: *

I believe that a good relationship between me and the Service User depends upon: *

I believe that I learn best when: *

I believe that a good working team is made by: *

I believe that my role in relation to the Service User is: *

My other beliefs and values relevant to my job role are: *

01206913222

APPLICATION FORM

Complete Your QCM Job Application

Role Preferences

Role Details

Personal Details

Residential Address History (Last 5 Years)

Current Address *

Driving & Eligibility

Equality & Adjustments

Education

High School (Secondary School)

Higher Education 1 (University/College)

Special Trainings

Employment History

Current/Most recent employer *

Previous employer 1

References

Professional Reference 1

Professional Reference 2

Professional Reference 3

Character Reference 1

Safeguarding/Ex-Offenders Declaration

Privacy Statement

Declaration

Supporting Statement

Values Based Screening Questions

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QCM Healthcare, Cadman House, Maurice Way, Peartree Road, Essex, CO3 0NW

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qcmhealthcare.co.uk

01206913222
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