Do you have all your documents *

 Yes No

Surname*

First Name*

Address*

Town / County*

Post Code*

Home/Telephone Number

Mobile Number*

Email Address*

Date of Birth*

Age*

Place of Birth*

Nationality*

Gender*

 Male Female

Emergency Contact Name*

Relationship to You*

Emergency Contact Number*

Passport / ID Number*

Passport / ID Date of Issue*

Passport Date of Expiry*
Please mention Not Applicable if you do not hold a passport

Is Visa / Work permit Necessary*

Do you give permission for Norma Lewis Nannies to carry out a “right to work check? (If applicable)

 Yes No

Marital Status*

 Single Married Divorced Widowed

Do you have any children*

 Yes No

If yes, what are their ages

What is your NI Number*
Please write I Do Not Have One , if that is the case

Position Required

Are you looking for a position
that is*

 Long Term Short Term Either

Are you looking for a job that is*

 Live In Live Out Either

Minimum length of job required*

Maximum length of job required*

Available to Start From*

Minimum salary accepted per week or per hour (NET)*

Are you happy to help with personal care such as washing and dressing *

 For a man For a woman Either

Are you happy to do housework as part of the job *

 Yes No

Are you happy to cook as part of the job *

 Yes No

Will you travel with the person if required

 Yes No

Do you have any visa / passport restrictions on travel

 Yes No

What are these restrictions

Do you speak any other languages

Are you happy to live with a person with pets

 Yes No

Are there any animals you really dislike

Would you help with pets as part of your job

 Yes No

Are you happy to live with a person with a different religion to your own

 Yes No

Your Qualifications and Experience

Your level of education, and any certificates you hold

Have you been a companion previously

 Yes No

• Your present occupation and duties in brief, and your current salary

Enter names, addresses, and tel numbers for minimum 2 referees. (Previous UK employers) *

Driving

Do you have a current full driving license *

 Yes No

Is it valid for driving in the UK *

 Yes No

Have you driven in the UK

 Yes No

Do you have any points or endorsements

 Yes No

If so, how many and for what

Can you drive
Auto

 Yes No

Manual

 Yes No

Do you have your own car *

 Yes No

More Details

Are you under medical treatment for any condition Please explain*

Is there any reason that you could not safely fulfill your duties*

 Yes No

Do you have any allergies If so, to what, and to what extent

Are there any foods you never eat

Do you smoke *

 Yes No

If yes, how many per day

Are you prepared to promise that you will not smoke in the house*

 Yes No

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). *

 Yes No

Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this post?*

 Yes No

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.

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.)*

 Yes No

Do you authorise Norma Lewis Nannies to apply for a DBS on your behalf *

 Yes No

Do you authorise Norma Lewis Nannies to disclose the information on your DBS to future employers?)*

 Yes No

And Finally ..

Do you have any knowledge of First Aid

 Yes No

Would you like information on First Aid courses*

 Yes No

Would you like information on Ofqual Safeguarding *

 Yes No

How did you hear of this agency *

What other agencies have you contacted*

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

1. I declare that I am medically fit, and have no condition that would mean I could not safely be left to discharge my duties.
2. 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.
3. 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.
4. 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.
5. I will not privately approach any employer introduced to me by Norma Lewis for work.
6. I will pay for any private telephone bills incurred during my placement.
7. 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.
8. 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.