Do you have all your documents *
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Yes No
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Personal Details |
Surname*
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First Name*
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Address*
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Town / County*
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Post Code*
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Home/Telephone Number
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Mobile Number*
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Email Address*
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Date of Birth*
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Age*
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Place of Birth*
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Nationality*
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Gender*
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Male Female
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Emergency Contact Name*
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Relationship to You*
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Emergency Contact Number*
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Passport / ID Number*
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Passport / ID Date of Issue*
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Passport Date of Expiry* Please mention Not Applicable if you do not hold a passport
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Is Visa / Work permit Necessary*
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Do you give permission for Norma Lewis Nannies to carry out a “right to work check? (If applicable)
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Yes No
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Marital Status*
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Single Married Divorced Widowed
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Do you have any children*
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Yes No
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If yes, what are their ages
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What is your NI Number* Please write I Do Not Have One , if that is the case
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Position Required
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Are you looking for a position that is*
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Long Term Short Term Either
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Are you looking for a job that is*
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Live In Live Out Either
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Minimum length of job required*
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Maximum length of job required*
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Available to Start From*
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Minimum salary accepted per week or per hour (NET)*
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Are you happy to help with personal care such as washing and dressing *
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For a man For a woman Either
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Are you happy to do housework as part of the job *
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Yes No
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Are you happy to cook as part of the job *
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Yes No
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Will you travel with the person if required
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Yes No
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Do you have any visa / passport restrictions on travel
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Yes No
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What are these restrictions
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Do you speak any other languages
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Are you happy to live with a person with pets
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Yes No
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Are there any animals you really dislike
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Would you help with pets as part of your job
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Yes No
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Are you happy to live with a person with a different religion to your own
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Yes No
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Your Qualifications and Experience
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Your level of education, and any certificates you hold
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Have you been a companion previously
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Yes No
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• Your present occupation and duties in brief, and your current salary
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Enter names, addresses, and tel numbers for minimum 2 referees. (Previous UK employers) *
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Driving
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Do you have a current full driving license *
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Yes No
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Is it valid for driving in the UK *
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Yes No
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Have you driven in the UK
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Yes No
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Do you have any points or endorsements
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Yes No
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If so, how many and for what
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Can you drive Auto
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Yes No
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Manual
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Yes No
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Do you have your own car *
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Yes No
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More Details
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Are you under medical treatment for any condition Please explain*
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Is there any reason that you could not safely fulfill your duties*
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Yes No
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Do you have any allergies If so, to what, and to what extent
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Are there any foods you never eat
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Do you smoke *
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Yes No
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If yes, how many per day
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Are you prepared to promise that you will not smoke in the house*
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Yes No
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Have you ever been convicted by the courts or cautioned, reprimanded or given a final warning by the police? (Note the post you have applied for is exempted under the Rehabilitation of Offenders Act 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need be disclosed). *
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Yes No
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Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this post?*
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Yes No
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If you have answered “yes” to either of the above questions, please send details of offences, penalties and dates, in confidence, to Norma Lewis, at norma@normalewisnannies.co.uk
This information will only be seen by those who need to see it as part of the recruitment process.
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You need to have an enhanced DBS Disclosure together with a status update certificate where there is regular contact with the elderly or vulnerable.
Do you hold a current enhanced disclosure certificate? (DBS check.)*
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Yes No
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Do you authorise Norma Lewis Nannies to apply for a DBS on your behalf *
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Yes No
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Do you authorise Norma Lewis Nannies to disclose the information on your DBS to future employers?)*
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Yes No
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And Finally ..
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Do you have any knowledge of First Aid
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Yes No
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Would you like information on First Aid courses*
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Yes No
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Would you like information on Ofqual Safeguarding *
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Yes No
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How did you hear of this agency *
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What other agencies have you contacted*
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APPLICANT DECLARATION
Submitting this form in any format to the Norma Lewis Nannies Agency shows that you have read, understood, and accepted the following Terms, and agree to be bound by them
TERMS
- I declare that I am medically fit, and have no condition that would mean I could not safely be left to discharge my duties.
- I declare that to the best of my knowledge, all the above information within my application is correct and true. Should any information change, I will notify Norma Lewis Nannies immediately.
- I authorise Norma Lewis Nannies to disclose to potential employers those of my confidential details (both personal and professional ) that are necessary to help find me work.
- Once I have been offered a position, and after I have accepted, I will notify the agency immediately. I will not start my new position until after I have received my confirmation of employment details from Norma Lewis.
- I will not privately approach any employer introduced to me by Norma Lewis for work.
- I will pay for any private telephone bills incurred during my placement.
- If for any reason I wish to terminate my contract of employment before the completion of my first 10 weeks’ employment, I will inform Norma Lewis (telephone 07956 89 45 89) prior to notifying my employer.
Furthermore, I must complete the correct Notice period as agreed with my Employer, subject to certain exceptions to be discussed with Norma Lewis.
Failure to comply with the above means that I will automatically be deemed to be "In breach of contract" with both the Agency, and the employer. In such an event, I will be subject to a penalty equivalent to one week's salary, payable to the Agency.
- I understand that I can be given notice, or summarily dismissed if
a) I fail to abide by this agreement
b) I have given false information on my application form
c) I break the law, or act in a way that endangers any person in my care.
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Name * |
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Date * |
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