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Personal Details

Own Transport
Clean Current Drivering Licence


Training History/ Professional Status

Additional Course Attended

Employment History

Assistance with Interview and Assessment

Do you require any special arrangements in order for you to participate in the recruitment process? i.e., large print forms or additional time to complete forms?

Any offer of employment may be made subject to a satisfactory medical report

Your GP will never be contacted without your permission

Next of Kin

Identity Details

Capacity to Work in the UK

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?
If you are successful in the application, would you require a work permit prior to taking up employment?


Current or Most Recent Employer Reference

Additional Employer Reference

Criminal Record

  • Workers of this company are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.


  • Please note, you may not be eligible for work in a care setting if you are on the DBS register(s).

Signature and Declaration – Important – Read Before Signing

I declare that to the best of my knowledge and belief, the information given by me in this application is true and I understand that the above information forms the basis on my contract of employment. I understand that if any the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.

I understand that I may not be offered a post until a satisfactory response has been received with respect to my DBS Register status and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer.

I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work and will not seek or have unsupervised access to vulnerable people.

By my signature, I authorise Utmostcare Ltd to request a DBS Register check and a criminal record check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence, including motoring offences, the administering of a warning, criminal conviction or referral to any register of barred care workers.

I also consent to Utmostcare Ltd. sharing my personal information with Local Authorities, Regulatory Bodies and Senior Management of Utmostcare Ltd.

We are an equal opportunities employer and welcome applications from suitably qualified persons regardless of their race, sex, disability, religion/belief, sexual orientation or age

Suitability for the Job

Please  confirm that you have read and understood the attached Job Description.

The position for which you are applying requires physical effort (including sitting, standing, carrying, walking, moving and handling people), mental effort (including dealing with emergencies and short-notice changes to work in a fast-paced environment) and possible emotional/psychological effort(including dealing with bereavement and challenging behaviour in a potentially stressful environment).

Do you have any health conditions that would prevent you from meeting these intrinsicrequirements for which the company might need to make reasonable adjustments?

(If yes, please be detail below and be aware that we may need to discuss these with you at your interview).
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