Personal Information


Emergency Contact

Professional Registration


Professional Indemnity Insurance

Nationality and Eligibility to Work


Evidence is required of all passports and visas. Please enclose or send scanned copies or photocopies with this application and bring the originals to your first interview. To work in the NHS you will be expected to communicate proficiently in English. All passports and visas will be verified as part of our recruitment procedure.

Educational Qualifications



You are required to complete the following practical training on an annual basis. (please tick the relevant courses you have completed and that you will be sending us a valid original certificate)

Place where obtained
Manual Training
Basic life support
Immediate Life Support (if applicable)
Food Hygiene
Safeguarding Children and Young People (POCA) Level 2
Additional Training

Previous Work Experience


Applicable Experience


Payment Details

Please note if you wish to be paid via a limited company then please see below for the documentation that you must provide at the interview, otherwise you will be paid via PAYE until all relevant documents are received.

  • Limited Company Corporation Certificate
  • Limited Company Bank Letter
  • Limited Company Bank Details Form

Your Professional Conduct


Rehabilitation Of Offendors Act

Convictions will not necessarily be a bar to obtaining a post. However because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974. Applicants are therefore required to declare information about convictions, cautions, reprimands and final warnings, for which other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the order applies.



Please provide us with the names of two people who can provide us with a reference as to your suitability for this post. The first one should be your present (or most recent) employer. You should tell us if this is not the case.


    In accordance to the Working Time Regulations 1998 (as amended), I consent to work in access of 48 hours per week. I understand that I may withdraw this consent by giving Highland Care Agency Limited not less than three months’ notice.