Application for employment

* Required

Title DR MISS MR MRS MS

First Name *

Last Name *

Email Address *

Date of Birth *

Home Address *

Town / City *

County / State *

Postcode / Zipcode *

Country * -- Select Country -- AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CâTE D'IVOIRE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE

Home Phone Number *

Work Phone Number *

Mobile Phone Number *

Please indicate which areas of Ark you are interested in working in: Home Care Complex Care  Head Office
Please attach your CV:
Position applied for:	Reference no:
Driving licence Yes No	Groups B B1 fkp
Driving licence expiry date *
Details of any endorsements
NI Number
Are there any restrictions on you taking up work in the UK? * yes no
If yes, please provide details
Registration/PIN (Nursing)
GMC Certificate Number (Doctors)
Are you willing to work as a live-in carer ? Yes No
If yes, are you willing to travel to any area? Yes No

Schools / Dates / Qualification gained

College/University / Dates / Qualification gained

Other training

Other employment Please note any employment you would continue with if you were to be successful in obtaining this position
Leisure Please note here your leisure interests, sports and hobbies, or other pastimes, etc.
Employment history Please enter: - Name and address of employer - Job title and duties - Salary on leaving - Reason for leaving - Starting with your most recent employment and give reasons for any gaps in employment.
References Please provide details of two referees who can provide information relating to your competency in a caring role, one of whom must be your present or most recent employer (referees for qualified Nurses must be professionals). If you are a student, please give an academic referee. If you are applying for a post which requires unsupervised access to children/vulnerable adults, we reserve the right to approach any past employer for a reference.
Reference 1	Reference 2
May we approach the above (ref1) prior to the interview? Yes No	May we approach the obove (Ref2) prior to the interview? Yes No
General comments Please detail here your reasons for this application, your main achievements to date and the strengths you would bring to this post. Specifically, please detail how your knowledge, skills and experiences meet the requirements of this role (as summarised in the person specification).
Cautions, rehabilitation and criminal records 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 Exceptions Order 1975 as amended by the Exceptions (Amendment) Order 1986, which means that convictions that are spent under the terms of the Rehabilitation of Offenders Act 1974 must be disclosed, and will be taken into account in deciding whether to make an appointment. Any information will be completely confidential and will be considered only in relation to this application. In addition you are required to submit to a Criminal Records Bureau check. Any standard or enhanced disclosure made by the CRB will remain strictly confidential.
Have you ever been convicted in a Court of Law and/or cautioned in respect of any offence? * Yes No
If YES, please give details

Special requirements (care sector)
Because this position involves the care of children and/or vulnerable adults employment is dependent on the following:
1. Your written consent to obtaining a standard/enhanced disclosure certificate from the Criminal Records Bureau or an approved umbrella body.
2. Such disclosure being acceptable to us.
3. Proof of identity – birth or marriage certificate (where appropriate) and passport (if available).
4. Two satisfactory written references.
5. That you will supply a photograph of yourself for retention in your records.
6. Evidence of physical suitability for your work.

Declaration (Please read carefully before signing this application)
1. I confirm that the above information is complete and correct and that any untrue or misleading information will give my employer the right
to terminate any employment contract offered.
2. Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my personnel file during employment and for up to six years thereafter and understand that information will be processed in accordance with the Data Protection Act.
3. I agree that my previous employers may be approached for references. I also agree that should I be successful in this application, I will, if required, apply to the Criminal Records Bureau for a standard or enhanced (as appropriate) disclosure. I understand that should I fail to do so, or should the disclosure or reference not be satisfactory, any offer of employment may be withdrawn or my employment terminated.

Declaration * I have read and agree to the declaration

Thank you for completing the application form.  To submit your application form please answer the following security question: What is the capital of England?