Job Application

Applicant Details

Personal Information

Titles

First Name

Middle Name

Last Name

Have you changed your name since birth?

Yes No

Date of birth

Nationality

Gender

Job Role

We will use your mobile number and email address to contact you about this job application. Please make sure these details are up-to-date, and you are happy for us to contact you on them.

Your Contact Details

Email Address

Phone Number

Your Contact Address

Address

Town/City

County

Country

Post Code

How long have you lived here?*

Years

Month

Contact Preference

Best Contact Option

Best Time To Contact

Next Of Kin

Next of Kin Information

Titles

First Name

Middle Name

Last Name

Relationship

Next of Kin Contact Details

Email Address

Phone Number

Employment Preferences

At 365 Care Services, we provide care and support to vulnerable people of all ages, from young people to the elderly. We recruit professionals including registered mental health nurses, general nurses, social workers, and support workers, with the shared goal of achieving the best possible outcomes for the people we care for.

Please note: Your answers in this section will not affect the outcome of your application. This information is collected only to help us understand your preferences and to support our social value objectives.

Do you hold personal indemnity cover?

Yes No

Are you currently in Employment, Education or Training?

Yes No

How far are you willing to travel for work?

Preferred work location(s)

Employment History

Please provide details of your employment history for the past 10 years, starting with your current or most recent job. If there are any break(s), these should be included along with the reason(s) for the break(s). Any temporary and agency work experience should also be included.

Does your CV cover at least 5 years and is dated with months.?

Yes no

Employment Reference One

Full Name

Phone Number

Company Email Address

Company Name

Employment Reference One

Full Name

Phone Number

Company Email Address

Company Name

Qualifications

This section helps us understand your qualifications, training, and experience so we can match you to the right role and ensure the people we support receive safe and high-quality care.

Do you currently have any illness, impairment, or disability (physical or psychological) that may affect your work?

Yes No

If Yes, is your degree related to health, social care, or psychology?

Yes No

Do you hold a Level 2 or Level 3 Diploma/NVQ/QCF in Health and Social Care?

Yes No

Do you hold a Level 3 Diploma in Residential Childcare (or equivalent)?

Yes No

Do you hold the Care Certificate?

Yes No

Do you hold any professional registration (e.g., NMC, HCPC, Social Work England)?

Yes No

Specialist Training

This section helps us understand your qualifications, training, and experience so we can match you to the right role and ensure the people we support receive safe and high-quality care.

Have you completed PMVA / MAPA / Physical Intervention training?

Yes No

Have you completed Safeguarding Children training (Level 2 or 3)?

Yes No

Have you completed Safeguarding Adults training?

Yes No

Have you completed training in Autism & Learning Disabilities?

Yes No

Have you completed Mental Health Awareness training?

Yes No

Have you completed training in Trauma-Informed Practice?

Yes No

Experience

This section helps us understand your qualifications, training, and experience so we can match you to the right role and ensure the people we support receive safe and high-quality care.

How many years of experience do you have in the care sector?

Less than 1 Year 1-2 Years 3-5 Years More than 5 Years

How many years of experience do you have in community or home-based care?

Less than 1 Year 1-2 Years 3-5 Years More than 5 Years

How many years of experience do you have in residential children’s care homes?

Less than 1 Year 1-2 Years 3-5 Years More than 5 Years

Core Skills & Competencies

Right to Work

By law, we must check that everyone we employ has the legal right to work in the UK. This applies to all employers, not just 365 Care Services.

Do you currently have the legal right to work in the UK?

Yes No

If yes, please indicate your status:

Does your right to work have any restrictions?

If applicable, please provide the expiry date of your visa or work permit.

Do you have Proof of National Insurance ?

Yes No

What is your National Insurance Number?

I have read and understood that I have to proof my right to work

Yes No

Disclosure and Barring Service (DBS) Checks

Because our roles involve working with children and vulnerable adults, we must carry out a DBS check (criminal record check).

Having something on your record doesn’t always stop you from working with us we review each case fairly. All information you share will be kept confidential.

Do you hold a DBS check carried out within the last 3 years?

Yes No

What is your DBS Certificate Number?

DBS Issue Date

Are you registered on the DBS update service?

Yes No

Have you changed your nationality since birth?

Yes No

I consent to 365 Care Service using the information provided to apply for a DBS or PVG on my behalf.

Yes No

I have read and understood the DBS Statement.

Yes No

Do you have any convictions that are not protected by the Rehabilitation of Offenders Act that have been issued by a court or court-martial in the United Kingdom or any other country?

Yes No

Do you hold any form of current Security Clearance?

Yes No

Have you ever received a police caution, reprimand or final warning?

Yes No

Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of?

Yes No

Are you aware of any current police investigation in the United Kingdom or in any other country following allegations made against you?

Yes No

Are you aware of any current NHS Counter Fraud and Security Management Service (NHS CFSMS) investigation following allegations made against you?

Yes No

Have you ever been dismissed by reason of misconduct from any employment, office or other position previously held by you?

Yes No

Have you been investigated by the Police, NHS CFSMS or any other Investigatory Body resulting in a current conviction or dismissal from your employment?

Yes No

Have you ever been disqualified from the practice of a profession, or required to practice subject to specified limitations following fitness to practice proceedings, by a regulatory or licensing body in the United Kingdom or in any other country?

Yes No

Are you subject to any other prohibition, limitation, or restriction that means we are unable to consider you for the post?

Yes No

Are you currently the subject of any investigation or fitness to practice proceedings by any licensing or regulatory body in the United Kingdom or in any other country ?

Yes No

Occupational Health Questionnaire

The purpose of this questionnaire is to help us ensure that all staff are fit to carry out their roles safely and to identify any support or adjustments you may need. The information you provide is confidential and will not affect your application outcome it is for occupational health purposes only.

Employment Reference One

GP Name

GP Practice Name

GP Address

GP Contact Number

1. General Health

Do you currently have any illness, impairment, or disability (physical or psychological) that may affect your work?

Yes No

Have you ever had any illness, impairment, or disability that was caused or made worse by work?

Yes No

Are you currently receiving, or waiting for, any treatment, medication, or investigations?

Yes No

Do you feel you may need any workplace adjustments or assistance to carry out your role?

Yes No

2. Infectious Diseases and Immunisations

Have you ever contracted MRSA?

Yes No

Have you ever contracted Clostridium Difficile (C-Diff)?

Yes No

Have you ever had Chickenpox or received the Varicella Zoster vaccination?

Yes No

Have you ever come into contact with blood-borne viruses (including needle-stick injuries)?

Yes No

Have you lived outside the UK or had an extended stay abroad in the last year?

Yes No

Have you had a BCGvaccination for Tuberculosis?

Yes No

Have you ever had or been in contact with someone with Tuberculosis (TB)?

Yes No

Have you experienced any unexplained weight loss or persistent unexplained fever?

Yes No

2. Infectious Diseases and Immunisations

Have you had the following immunisations? Please tick all that apply.

Triple childhood vaccination (Diphtheria / Tetanus / Whooping Cough) Polio Tetanus booster Hepatitis B (full course and/or booster)

Declaration & Consent

This section sets out the important points you need to agree to before working with 365 Care Services. It covers accuracy of your information, confidentiality, working conditions, background checks, data protection, and pensions.

Please read each statement carefully and tick the box to confirm that you understand and agree.

1. Accuracy of Information ( I promise my application is honest and correct.)

Falsification, or misrepresentation may lead to my application being rejected or, if employed, to my dismissal. Where applicable, I consent to 365 Care Services verifying my professional registration details.

1. Accuracy of Information

I understand and agree

2. Challenging Behaviour ( I know some service users may show difficult behaviour, and I can choose whether to accept or leave an assignment.)

Services. I understand that as an agency worker I am under no obligation to accept any assignment, and that I may withdraw by giving reasonable notice in line with my contract. I accept that such risks are part of the industry and agree that the agency is not liable for any injury or loss of earnings arising from such situations.

2. Challenging Behaviour

I understand and agree

3. Confidentiality Agreement ( I will keep all client and service user information private and secure.)

I agree to maintain strict confidentiality regarding all information relating to service users, clients, and 365 Care Services during and after assignments. I will ensure that information is kept securely and will not remove any information from client premises without permission.

3. Confidentiality Agreement

I understand and agree

4. Working Time Directive ( I don’t have to work more than 48 hours a week unless I choose to.)

I understand that I am not required to work more than an average of 48 hours per week (including work with other employers). I may choose to work more hours, but this is entirely voluntary. I agree to inform 365 Care Services if my total weekly hours across all employment exceed 48, so this can be taken into account before offering further work.

4. Working Time Directive

I understand and agree

5. References and Checks ( I understand the job depends on references and DBS checks. )

I understand that my employment is subject to receipt of at least two satisfactory references and, where required, a Disclosure and Barring Service (DBS) check or overseas police check. I consent to 365 Care Services making any necessary enquiries to support my application.

5. References and Checks

I understand and agree

6. Confidentiality of Policies and Procedures ( I will respect confidentiality at all times and follow company policies.)

I confirm that I will respect the confidentiality of patients, clients, and sensitive information at all times. I also acknowledge that I can access the organisation’s policies and procedures online, or request paper copies if needed.

6. Confidentiality of Policies and Procedures

I understand and agree

7. Consent for Training, DBS, and Equipment Deductions ( I agree that reasonable costs for mandatory training, DBS checks, or equipment may be taken from my pay once I have worked.)

I understand and consent that from time to time 365 Care Services may arrange mandatory training, DBS checks, or provide necessary equipment for me to carry out my role. I agree that the cost of these items may be deducted from my payslip after I have received payment for services provided.

7. Consent for Training, DBS, and Equipment Deductions

I understand and agree

8. Duty to Disclose New Offences: ( I confirm I am not under any safeguarding investigation or allegation that would stop me from working with vulnerable people.)

I understand that I must inform 365 Care Services immediately if I am charged with any offence in the United Kingdom or in any other country after completing this form and before taking up any position offered to me.

8. Duty to Disclose New Offences

I understand and agree

9. Safeguarding Investigations and Allegations: ( I confirm I am not under any safeguarding investigation or allegation that would stop me from working with vulnerable people.)

I declare that, at the time of this application and throughout my employment with 365 Care Services, I am not subject to any safeguarding investigation, restriction, or allegation by any organisation, authority, or regulatory body that would prevent me from working with children, young people, or vulnerable adults. I agree to inform 365 Care Services immediately if this changes at any point during my employment.

9. Safeguarding Investigations and Allegations

I understand and agree

10. GDPR & Data Protection Consent: ( I allow 365 Care Services to use my data for recruitment, compliance, and pay.)

In line with the UK GDPR and the Data Protection Act 2018, I consent to 365 Care Services processing my personal data for recruitment, compliance, and payroll purposes. This may include:

Contacting me by phone, text, or email about shifts, compliance, or training.
Sharing my details with approved third parties where required (e.g. DBS checks, occupational health, payroll, training verification).
Contacting previous employers for references.
Storing my data securely for the required statutory retention period.

I understand I can withdraw consent at any time by contacting the Data Protection Officer at 365 Care Services.

10. GDPR & Data Protection Consent

I understand and agree

11. Pension Auto-Enrolment Declaration: ( I understand I’ll be auto-enrolled into a workplace pension, but I can choose to opt out.)

In line with the Pensions Act 2008, I understand that if I meet the eligibility criteria, I will automatically be enrolled into the company pension scheme. I also understand that:

I have the right to opt out of the pension scheme after enrolment,
If I choose to opt out, I must complete the official opt-out form provided by the pension provider, and
Any pension contributions already deducted will be refunded in line with statutory rules if I opt out within the required timeframe

11. Pension Auto-Enrolment Declaration

I understand and agree

Compliance Checklist

To complete your application with 365 Care Services, please email copies of the required documents to: compliance@365careservices.co.uk

“Subject line format: Full Name – Position Applied For – Area (e.g., Jane Doe – RMN – Liverpool)”

If any training or certificates are missing or expired, please tick Pending and we will arrange the required training.

1. Identity & Right to Work:

Valid passport or photo ID (driving licence/national ID) National Insurance proof (NI letter, P45, payslip, HMRC letter) Right to Work evidence (visa/BRP/share code if applicable) Two proofs of address (dated within last 3 months)

2. Background Checks

Enhanced DBS (Child & Adult Workforce) on the Update Service (Front and Back Pages) References covering the last 3 years (at least one from most recent employer) Full CV with complete 5 years employment history (explain gaps over 4 weeks) Overseas Police Check (if lived outside the UK for 6+ months in last 5 years)

3. Professional Registration (roledependent)

NMC PIN (RMN/RGN) – screenshot or card Copies of relevant qualifications (degree, diploma, certificates) HCPC / Social Work England / BPS (as applicable)

5. Occupational Health & Fitness

Occupational Health clearance / Fit to Work Medical self-declaration form Immunisations (Hep B, MMR, TB, Covid-19 where relevant)

6. Other Compliance

Professional indemnity insurance (for self-employed/agency nurses Car insurance with business use Proof of Company and Company Bank Right to use vehicle Details Driving licence Bank details Right to use vehicle

Please use CAPITAL Letters

Time Sheet

03303904008 www.365careservices.co.uk timesheets@365careservices.co.uk

Full Name*

Staff Grade*

Client*

Weekeding*

Date	Start Time	Finish Time	Break	Total Hours	Client Site	Client Signature
Week DD MM YYYY
Week DD MM YYYY
Week DD MM YYYY
Week DD MM YYYY
Week DD MM YYYY
Week DD MM YYYY
Week DD MM YYYY
		Total Weekly Hours

Your Signature:

I can confirm that the above hours are correct and that I performed my duties to the best of my ability.

Date*:

Signature*:

Client Signature:

I can confirm that the (above) has completed the above hours. I am authorized within my position to sign this time sheet.

Full Name*: Date*: Position*:

Signature*:

A copy of this timesheet needs to be with us by 10am Monday, so that we can pay you on time. To send your timesheet, email a scanned copy or photo to timesheets@365careservices.co.uk and it is mandatory to upload the timesheet to our system. If you are going to email a scanned copy or photo across, we recommend that you CC yourself on the email. If you see your email in your inbox, it means we also should have received it.

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