EMPLOYMENT HISTORY / WORK EXPERIENCE Please record all employment in the past 5 years, including current employment by other agencies, and any other relevant experience gained within the health care field. Please start with the most recent. Please note that we shall obtain a reference from your LAST EMPLOYER REFERENCES 1A) Must be your most recent employer (of at least 3 months duration) which must correspond with your employment history.

EMPLOYMENT HISTORY / WORK EXPERIENCE Please record all employment in the past 5 years, including current employment by other agencies, and any other relevant experience gained within the health care field. Please start with the most recent. Please note that we shall obtain a reference from your LAST EMPLOYER REFERENCES 1A) Must be your most recent employer (of at least 3 months duration) which must correspond with your employment history.

EMPLOYMENT HISTORY / WORK EXPERIENCE Please record all employment in the past 5 years, including current employment by other agencies, and any other relevant experience gained within the health care field. Please start with the most recent. Please note that we shall obtain a reference from your LAST EMPLOYER REFERENCES 1A) Must be your most recent employer (of at least 3 months duration) which must correspond with your employment history.

HEALTH DECLARATION Careers support workers are required to complete this Health Declaration. Any positive answers will not necessarily affect your application. Please list any medical conditions (past or present) which may affect your ability to do the job. OCCUPATIONAL HEALTH ASSESSMENT

HAVE YOU EVER BEEN VACCINATED, IMMUNIZED OR TESTED FOR / AGAINST ANY OF THE FOLLOWING?

DOCTOR INFORMATION

WORK PREFERENCE To assist us in finding suitable work for you, please place a tick next to all specialties of which you have significant recent experience and are confident to carry out such duties. Please keep us informed from time to time of all developments in your career as the work we assign to you depends on accurate up to date information.

LIVE-IN CARE

CARE/SUPPORT ASSISTANT ABILITY SCHEDULE Please select the areas you have had previous experience.

EQUAL OPPORTUNITIES MONITORING Humble Healthcare Care Ltd aims to be an equal opportunities employer. Employees are therefore put forward for work / shift irrespective of race, ethnic origin, disability, age and gender. In order to monitor the effectiveness of our policy, we request all candidates to provide the following information.

REHABILITATION OF OFFENDERS ACT 1974 You are advised that you are not entitled to withhold information about convictions, which are regarded as spent under the Act’. This is due to the nature of the work involved renders the post exempt from sec. 4(2) of the Act in accordance with the Rehabilitation of Offenders Act 974 (Exceptions) Order 1975. You are therefore required to give details of all convictions and cautions including ‘spent’ convictions. Any in formation, which you may give, will be strictly confidential and will be considered only in relation to this or a similar position for which you may be considered with Humble Healthcare Care Ltd