Title Mr Ms Miss Mrs Dr Prof Other
Date of Birth
Place of Birth
Mobile Phone No
Address (Number, Street & Town)
How long have you lived at this address?
If less than five years, please give previous address(es) & postcode(s) up until this period
Have you ever lived outside the United Kingdom?
Do you need a permit to work in the United Kingdom?
Have you ever changed your name by deed poll?
If so, what was your previous name?
What is your National Insurance Number?
Are you registered with any regulatory body? e.g. NISCC
Do you hold a current driving licence?
Do you have business car insurance?
Are you prepared to work?
Are you prepared to work?
What availability do you have?
What date can you commence work? Previous Employment (Beginning with most recent): Employment Gaps (Fill out if necessary):
INDEPENDENT SAFEGUARDING AUTHORITY
INFORMATION KNOWINGLY OR WILFULLY WITHHELD TO OBTAIN EMPLOYMENT WILL RESULT IN SUMMARY DISMISSAL
Is there a reason why you cannot work in regulated activity?
Reason for inability to work in regulated activity
M CARE (NI)
Disclosure of Criminal Background
Because of the nature of the work for which you have applied, this post is exempt from Article 5 of the Rehabilitation of Offenders Order Northern Ireland 1978, and the Rehabilitation of Offenders (Exceptions) Northern Ireland Order 1979 and requires that all convictions and cautions must be declared, and that no conviction can be deemed to be spent.
It is therefore necessary to ask the following questions
Have you ever been convicted of any offence?
Are you currently the subject of police investigation or any other body including the disclosure and barring service or do you have any prosecutions Pending?
List below details of all charges, prosecutions, convictions, cautions – even if they happened a long time ago. You must include any minor matters, any road traffic or motoring offences and any which may be pending. Please note that a disclosure of a conviction does not necessarily debar any applicant from obtaining employment.
The following policies are available on request
Policy on Access NI Security Policy Statement on Recruitment of ex-offenders
I understand that if an offer of employment is made, it is subject to an Access NI check.Access NI enables organisations in Northern Ireland to make a more informed recruitment decisions by providing criminal history information about anyone seeking paid/unpaid work in certain detained areas such as working with children or vulnerable adults.
For further details on Access NI and their code of practise this can be accessed on www.nidirect.gov.uk/accessni
Do you agree to an Access NI check? Please note that you will be expected to meet the cost of an Enhanced Disclosure Certificate.
Do you consent to MCare NI contacting your nominated referee(s) for a reference in respect of your application for employment?
Are you a registered disabled person?
Are you willing to undergo a medical examination, if required?
Have you ever suffered from, or do you currently suffer from any of the following?
Back pain, disc trouble, rheumatism, arthritis, gout Dermatitis, eczema, or other skin disorders Any form of alcohol or substance dependency Epilepsy, fainting attacks, or black outs Palpitations, shortness of breath, chest pain High blood pressure, or, any other ailment of the heart, lungs, Chest or Circulatory System Mental health issues e.g. Depresseion, anxiety or other Any visual or hearing defects Diabetes, anaemia, or, any blood or gland disorder Rheumatic fever, or any joint / muscular problems Recurring headaches Ulcers, gall stones, or any ailment of the intestines or liver Any known allergies Any other illness not referred to above. Do you use/take any prescribed or none prescribed drugs Do you have any other pre-existing health related condition that would impact your ability to work in regulated activity? None of the above Other Other
Further Details in reference to above
Please provide details of all absences from work due to illness or injury during the last year (Reason for absence & number of days)
Job Applicant Privacy Notice
Data controller: M CARE Introduction During the recruitment process, M Care (the Company) collects and processes personal data relating to job applicants. The Company is committed to being clear and transparent about how it collects and uses that data and to meeting its data protection obligations. What information does the Company collect and process? The Company collects and processes a range of personal information (personal data) about you. Personal data means any information about an individual from which the person can be identified. This includes: Personal contact details, such as your name, title, address and contact details, including email address and telephone number; details of your qualifications, skills, experience and employment history, including start and end dates, with previous employers; information about your remuneration, including entitlement to benefits such as pensions; information about your entitlement to work in the UK; and equal opportunities monitoring information, including information about your ethnic origin, sexual orientation, health and religion or belief. The Company collects this information in a variety of ways during the application and recruitment process. For example, data may be contained in application forms and CVs, obtained from identity documents, such as your passport and collected through interviews. In some cases, the Company collects personal data about you from third parties, such as references supplied by former employers, information from employment background check providers and information from criminal records checks permitted by law. Data is stored in a range of different places, including on your application record, in the Company’s HR management systems and in other IT systems (including the Company’s email system). Why does the Company process personal data? The Company needs to process data prior to entering into a contract with you. We also need to process data to enter into an employment contract with you and to meet our obligations under that employment contract. In addition, the Company needs to process data to ensure that we are complying with our legal obligations. For example, we are required to check an employee’s entitlement to work in the UK before employment begins. The Company has a legitimate interest in processing personal data during the recruitment process and in keeping records of that process. Processing such data from job applicants enables the Company to manage the recruitment process, assess the suitability of candidates and make informed decision as to whom we wish to recruit. The Company may also have to process data from job applicants in order to defend legal claims. The Company processes health information if we need to make reasonable adjustments to the recruitment process for candidates with a disability. For all positions, it is necessary to carry out criminal records checks to ensure that individuals are permitted to undertake a particular role. If you fail to provide personal information You are under no obligation to provide the Company with data during the recruitment process. However, if you do not prove certain information when requested, the Company may not be able to process your application for employment properly or at all. You are under no obligation to provide information for equal opportunities monitoring purposes and there are no consequences for you if this information is not provided. Automated decision-making Our employment decisions are not based solely on automated decision-making. For how long do you keep data? The Company will only hold your personal data for as long as is necessary to fulfil the purposes for which we collected it. If your application for employment is unsuccessful, the Company will hold your data on file for 1 year after the end of the recruitment process. At the end of that period, your data is deleted or destroyed. If your application for employment is successful, personal data gathered during the recruitment process will be transferred to your personnel file and we shall issue a new privacy notice which sets down the periods for which your data will be held. Who has access to data? Your information will be shared internally for the purposes of the recruitment process, including with members of the HR team and interviewers and Managers. The Company will not share your data with third parties unless we make you an offer of employment. In those circumstances, the Company shall share your data with third parties where required by law and where it is necessary in order to administer the working relationship with you or where we have another legitimate interest in doing so. The Company will then share your data with former employers and other statutory bodies as required. The Company will not transfer your data to countries outside the European Economic Area. How does the Company protect data? The Company takes the security of your data seriously. The Company has internal policies and controls in place to prevent your data being lost, accidentally destroyed, misused or disclosed, and is not accessed except by its employees in the performance of their duties. Your rights As a data subject, you have a number of rights. You can: access and obtain a copy of your data on request (known as a “data subject access request”); require the Company to change incorrect or incomplete data; request erasure of your personal information. This enables you to ask the Company to delete or stop processing your data, for example where the data is no longer necessary for the purposes of processing; object to the processing of your data where the Company is relying on its legitimate interests as the legal ground for processing; and ask the Company to suspend the processing of your personal data for a period of time if data is inaccurate or there is a dispute about its accuracy or the reason for processing it. If you would like to exercise any of these rights, or you have any questions about the privacy notice, please contact HR on 02890 333388 If you believe that the Company has not complied with your data protection rights, you have the right to make a complaint to the Information Commissioner’s Office. If you remain dissatisfied with the response to any complaint you have the right to lodge a complaint with the Information Commissioner’s Office (ICO) Information Commissioner’s Office (ICO) Wycliffe House Waterlane Wimslow Cheshire SK9 5AF Tel No: 0303 123 1113
I acknowledge receipt of the Privacy Notice for applicants and confirm that I have read and understood it.
I hereby consent to M Care contacting my nominated referee(s) for a reference in respect of my application for employment.
I declare that any answers are complete and correct to the best of my knowledge.
I agree to have my data processed by the MCare Administration team
Please type your name in full