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Michael Phillips Care Agency Ltd.
The following information will be treated with the strictest confidence. Only full and complete application forms will be processed.
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Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Number:
Mobile:
National Insurance Number:
Email:
Preferred contact option:
- E-mail
- Landline
- Mobile
Full Driving Licence:
- Yes
- No
Endorsements:
- *Yes
- No
*If YES, please give further details including dates

Education
Schools attended since age 11:
Name of school From To Examinations and Results
College or University:
Name of college/university From To Courses and Results
Further Formal Training
Description of Training From To Diploma/Qualification
Job related Training Courses
Name of Organisation Date Subject
Please give details of membership of any technical or professional associations:
Please list any languages spoken and the level of competence:

Employment details
Please give details; of at least, you’re past 6yrs employment history, excluding your present or last employer, stating the most recent first. Please provide information on any gaps in your employment history.
Name and address of employer Dates from/to Position held/Main duties Reason for leaving/Pay rate (per hr)
Before moving onto the next question, have you given details of any gaps in your employment history? Please ensure this is completed.
Present or Last Employer
Are you currently employed?
- Yes
- No
Name of present or last employer:
Address:
Telephone No:
Nature of business:
Job title and a brief description of your duties:
Reason for leaving: (if applicable)
Length of service:
From To

Interests, Achievements, Supplementary Information
Please set out below any further information to support your application, e.g. past achievements, future aspirations, personal strengths. What do you want from this job?
Availability
Please give details of the hours, days, times etc that you are looking to work. Are there any days you are unable to work? Would you like to also work weekdays/ weekends? Note: Please understand that working for MPCA Ltd involves unsociable hours. It is a requirement of the job that you may be working a number of mornings, days, evenings, weekends and/ or bank holidays. All contracts are based on variable hours.
Mon: Tue: Wed: Thur: Fri: Sat: Sun:
Abilities
Please indicate below, any past experience. This could be within your working environment or personal life. Please tick all that apply.
Personal Hygiene
- Bathing
- Showering
- Strip Wash
- Shaving
- Dressing
Toileting
- Continence care
- Commodes
- Catheter care
- Stoma care
Mobility
- Using a hoist
- Walking aids
- Moving & Handling
Practical tasks
- Housework
- Shopping
- Domestic
- Laundry
Nutrition
- Meal prep
- Food hygiene
Administration
- Report writing
- Care plan reports
Group Types
- Terminal illness
- Physically disabled
- HIV/Aids
- Mental health
- Learning disabilities
- Childcare
- Older people
- Sensory loss
- Dementia
- Drug & Alcohol
Previous Work
- Domiciliary
- Private client
- Hospital
- Nursing home
- Residential
Relevant Information
Please use this space to add any other details you may feel relevant to the abilities question.

Disclosures/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 an enhanced disclosure certificate from the Disclosure and Barring Service (DBS) or an approved umbrella body. 2. Such disclosure being acceptable to us. 3. Proof of identity – birth or marriage certificate (where possible) and passport (if available). A copy of your photographic driving licence will be held on file. 4. Two satisfactory written references. 5. That you will supply a photograph of yourself for retention in our records. 6. Evidence of physical or mental suitability for your work. Given the nature of the job applied for, in the event that I am offered the position, I understand that any offer of employment is subject to information on my criminal record being disclosed to the Company by the Disclosure and Barring Service (DBS). I have been given a copy of the company’s Equal Opportunities policy, which includes information relating to the recruitment of ex-offenders.
Working Times Regulations
If you do wish to work more than 48hrs per week, it is necessary to sign the form below to show that you are available.
I confirm that I want to be available to work more than 48hrs per week and that I will give you adequate notification in writing should I wish to reduce these hours to less than 48hrs.
Declaration
I declare that the information given on this legally binding document is complete and accurate. I understand that any false information or deliberate omissions will disqualify me from employment or may render me liable to summary dismissal. I understand the company will hold these details in confidence, for the purposes of assessing this application, ongoing personnel administration and payroll administration (where applicable) in compliance with the Data Protection Act. I give the prospective employer the right to make any other job-related enquiries as may be deemed necessary. The company will pay DBS costs, initially and any renewals thereafter and I agree that in the event that I leave within the first 26 weeks of my DBS issue date; I am required to pay back the cost of the DBS certification, via my final pay package.
Date:
References
Please give the names of two people (one of which must be your present or most recent employer) whom we may approach for a reference. Applications will NOT be processed if this information is not completed, IN FULL.
Can we approach your current employer before an offer of employment is made?
- Yes
- No
- Not Applicaable
First Reference:
Name:
Relationship to you:
Full address:
Postcode:
Tel. No:
Email:
Know for (months, years)
Second Reference:
Name:
Relationship to you:
Full address:
Postcode:
Tel. No:
Email:
Know for (months, years)
Source of application:
For example, indeed, gumtree, facebook, word of mouth, local press, job centre plus, company website)

For example, indeed, gumtree, facebook, word of mouth, local press, job centre plus, company website)

01745 350923

Employment Application Form

Step 1 of 7

Michael Phillips Care Agency Ltd.

Education

Employment details

Present or Last Employer

Interests, Achievements, Supplementary Information

Availability

Abilities

Relevant Information

Disclosures/Special Requirements (Care Sector)

Working Times Regulations

Declaration

References

Source of application:

EQUAL OPPORTUNITIES MONITORING

I would describe my ethnic group and sex as:- (please tick one box for your ethnic group and one box for your sex)

IMPORTANT MESSAGE:

Tel: 01745 350923

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Name and address of employer	Dates from/to	Position held/Main duties	Reason for leaving/Pay rate (per hr)

Name of school	From	To	Examinations and Results

Name of college/university	From	To	Courses and Results

Description of Training	From	To	Diploma/Qualification

Name of Organisation	Date	Subject