Tel: 01202 610 203

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Job Application Form

Personal Details

Bank Details

Preferred Hours

Next Of Kin Details

Education/ Qualifications
School/ College/ University
Qualification and Grade

Mandatory and Induction Training
(This applies to all healthcare and support workers)
Date Trained Expiry Date
Moving and Handling
Health and Safety
Food Hygiene
Fire Safety
Infection Control
Safeguarding of Vulnerable Adults
Personal Care
First Aid
Challenging Behavior
First Aid

Employment History

Current or most recent employer

Previous Employer

Convictions/ Disqualifications

To ensure the safety of our clients/members a DBS check must be completed for all positions. A criminal record will not necessarily be a bar to obtaining a job. If a check is returned and reveals any information, this will be discussed with the applicant. A decision will be made as to whether the offer of employment should be withdrawn.

Rehabilitation of Offenders Act 1974 (Exceptions)(Amendment) Order 1986
"Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act, 1974, by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986. Applicants are, therefore, not entitled to withhold information about convictions which for other purposes are 'spent' under the provisions of the Act".

Please provide details below if you have been convicted of a criminal offence or been the subject of a conditional discharge or probation order.


1st Referee

2nd Referee

Confidentiality declaration

Registration implies acceptance of our code of confidentiality.
In the course of your duties you may have access to confidential information about your clients. On no account must information relating to identifiable client be divulged to anyone other than the manager of the agency. You should not disclose ANY information to your family or friends.
If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER.
Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register.

I have read and I understand the above and I agree to abide by the contents therein.


I agree that AGA RECRUITMENT SOLUTIONS can create and maintain computer and paper records of my personal data and that this will be processed and stored in accordance with the Data Protection Act 1998.
I authorise AGA RECRUITMENT SOLUTIONS to obtain references to support this application once an offer has been made and accepted. I accept that any offer made is subject to the receipt of references and Criminal Records Bureau checks that are satisfactory to the Company. I understand that any engagement entered into is subject to a report on my health being satisfactory.
I also accept that it is my personal responsibility to notify the Company of any employment I accept other than the position for which I am employed and to declare on a weekly basis the actual hours worked.

I confirm that all the information given by me on this form is correct and accurate and I understand that if any of the information I have provided is later found to be false or misleading, any offer of employment may be withdrawn or employment terminated.


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