Application Form

Please complete fully our Online Application Form below.

Step 1 of 13

The Honeydew Healthcare recruitment process has a minimum of two stages. Completion of this application form is part of stage one. This application will be reviewed, and a decision made as to whether to proceed to stage two, the interview, based on this information.

Use this starter checklist to gather information about your new employee if they do not have a P45. You can also use this form if they have a student loan (whether or not they have a P45). Use the information to help fill in your first Full Payment Submission (FPS) for this employee. If you have already submitted your first FPS, keep using the tax code in that FPS until HMRC sends you a new tax code. If the employee gives you their P45 after the first FPS submission, use the tax code shown in parts 2 and 3 of the P45. You must keep the information recorded on the starter checklist for the current and next 3 tax years. This form is for your use only.

Fill in this form if you do not have a P45 (a document you get from your employer when you stop working for them). You should also fill in this form if you have a student loan (whether or not you’ve a P45). Give the completed form to your employer as soon as possible. They need this information to tell HMRC about you and help them to use the right tax code. Make sure you answer the questions correctly. If you do not, you may pay the wrong amount of tax or student loan deductions.

Employment Start Date

DD slash MM slash YYYY

These questions will help you to choose the statement that matches your circumstances. The statement you choose helps your employer to apply the correct tax code.

Do you have another job?

Yes

Do you receive payments from a State, workplace or private pension?

Yes

Since 6 April have you received payments from:

another job which has ended or any of the following taxable benefits • Jobseeker’s Allowance (JSA) • Employment and Support Allowance (ESA) • Incapacity Benefit

Yes

Do you have a student or postgraduate loan?

Yes

Do any of the following statements apply:

• you’re still studying on a course that your student loan relates to • you completed or left your course after the start of the current tax year, which started on 6 April • you’ve already repaid your loan in full • you’re paying the Student Loans Company by Direct Debit from your bank to manage your end of loan repayments

Yes

Position Applied For

Position applied for (please tick as appropriate):

Registered Mental Health Nurse (RMN)

Health Care Support Worker (HCSW)

Health Care Assistant (HCA)

Other

I understand this role may include: Shift work, Unsociable Hours, Lone working involved. (Please select your availability below)

Yes

How many hours per week can you work?

Preferred employment type:

Full-time

Part-time

Preferred employment type:

Days

Nights

Mornings

Afternoons

Evenings

Weekends

Tick all that apply

Applicant's Personal Details

Full Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Gender:(Required)

Please indicate your Gender

Female

Male

Transgender Female

Transgender Male

Non-binary / third gender

I do not wish to disclose my Gender

Other

Marital Status:(Required)

Please indicate your Marital Status

Common Law Partnership

Married / Civil Partnership

Widowed

Divorced

Single

Other

Current Address(Required)

Please enter your current address of residence.

Street Address Address Line 2 City Region Postcode Country

Date(Required)

DD slash MM slash YYYY

Date moved to current address (DD/MM/YYYY):

Have you lived at your current address for the past 5 years or more?(Required)

Yes

Previous Address(Required)

Please enter your previous address of residence if you haven't lived for more than 5 years at your current address (Note: for Criminal Record check purposes, addresses covering the five years up to the application date must be supplied.)

Street Address Address Line 2 City Region Postcode Country

Previous Address(Required)

Street Address Address Line 2 City Region Postcode Country

Previous Address(Required)

Street Address Address Line 2 City Region Postcode Country

Date moved to previous address (DD/MM/YYYY):(Required)

DD slash MM slash YYYY

Nationality(Required)

National Insurance Number(Required)

Nursing and Midwifery Council PIN number

Nurses Only

Telephone / Mobile number:(Required)

Email(Required)

Are you a driver?

Yes

Own Transport

Yes

N/A

How long have you had a licence?

Years

Any Endorsements:

Yes

N/A

Residence Status

*Are you a United Kingdom (UK) National?(Required)

Yes

Please provide more details of your residential status

*If No, please detail your current immigration status and the relevant visa currently held (including Visa number)

Capacity to work in the UK

(Note: Minimum age legislation specifies that care workers in general must be 16 years or older. Please inform your interviewer immediately if you do not meet this specification).

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?

Yes

If yes, please provide details:

Are you related to any of our current members of staff or Service Users?

Yes

Equality Act 2010 - Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a “substantial” and “long-term adverse effect” on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at: www.gov.uk/definition-of-disability-under-equality-actu00022010.

For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?(Required)

Yes

Rather not say

If Yes:

If you are successful in the application, would you require a work permit prior to taking up employment?

Yes

Education

Examinations, Qualifications*(Required)

(Please supply/attach below, copies of certificates. All qualifications will be subject to a satisfactory check).

School / College / University

Date From:

Date To:

Examinations Passed / Qualifications gained*

TRAINING HISTORY/PROFESSIONAL STATUS

(Please supply copies of certificates / membership details)

Date of Graduation/Qualification

Location / Details

Date

Notes

SHORT COURSES ATTENDED

Subjects

Location

Attach Supporting Documents

Drop files here or

Max. file size: 256 MB.

Employment History

Current/most recent first. Information must cover the whole of your working life to date. State the reasons for any breaks in employment. Use the Additional Information sheet (attached) if required; please sign each sheet of additional information submitted.

Current / Most recent employer

Start Date

DD slash MM slash YYYY

End Date

DD slash MM slash YYYY

Salary / Rate:

Job Role

Business Name

Reason for Leaving

Contact Name

Duties:

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Telephone

Employment History

You must provide references from your two most recent employers. Please provide details for an additional character referee. All will be contacted, therefore please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.

Start Date:

DD slash MM slash YYYY

End Date:

DD slash MM slash YYYY

Salary / Rate:

Job Role

Business Name

Reason for Leaving

Contact Name

Duties:

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Telephone

Additional Employment History

Date Employed

Salary / Rate:

Job Role:

Business Name:

Reason for Leaving:

Contact Name:

Address:

Telephone:

Email:

Address(Required)

Street Address Address Line 2 City County / State / Region Postcode Country

Detailed Explanation of Gaps

(Use this section to detail any gaps in employment and why)

Capacity in which known/ Relationship(Required)

References

Fill in the first reference

Full Names(Required)

Contact Name Business Name

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region Postcode Country

Capacity in which known/ Relationship(Required)

Fill in the second reference

Full Names(Required)

Contact Name Business Name

Address(Required)

Street Address Address Line 2 City County / State / Region Postcode Country

Capacity in which known/ Relationship(Required)

Email(Required)

Phone(Required)

Character reference

Full Names

Contact Name Business Name

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Capacity in which known/ Relationship

Phone

ASSISTANCE WITH INTERVIEW AND ASSESSMENT

Do you require us to make any special arrangements for you to participate in the recruitment process? For example, large print forms? Or additional time to complete forms?

Yes

If yes, please give details:

Any offer of employment may be made subject to a satisfactory medical report. (Your GP will not be contacted without your permission).

GP's Name

Full Name

GP's Tel no:

GP's Address

Street Address Address Line 2 City County / State / Region Postcode Country

Details of Next of Kin

Kin's Name:

Full Name

Relationship with Kin:

Kin's Email

Kin's Phone No:

Kin's Address

Street Address Address Line 2 City County / State / Region Postcode Country

Safeguarding / Ex-Offenders / Criminal Declaration

Safeguarding / Ex-Offenders Declaration: Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest confidence. Honeydew Healthcare Ltd employees 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. You will not be eligible for work in a care setting if you are on the DBS barred Register(s).

The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. Honeydew Healthcare Ltd undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

*Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country?(Required)

Yes

*Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country?(Required)

Yes

Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.

Signature

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 of my contract of employment. I understand that if any of 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 cannot 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, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will always be supervised at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise the organisation 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 (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status.

Privacy Statement

We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to us holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you). When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles. We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant post. You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Registered Manager to discuss.

Declaration

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that can seek clarification regarding professional registration details.

Consent(Required)

I agree to the privacy policy.

I agree that any deliberate omission, falsification or
misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if
employed. Where applicable, I consent that can seek clarification regarding professional registration details.

Supporting Statement

Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe particular strengths and talents that set you apart from others as well as including skills gained from work, home and other activities.

Your Supporting Statement

EQUAL OPPORTUNITIES MONITORING

Honeydew Healthcare is committed to promoting equal opportunities for all current and prospective employees. To ensure that all applicants are dealt with equally, we wish to monitor your recruitment process and would ask for your help by completing the details below. This will allow the organisation to monitor its policies.

You do not have to complete this form. Information is given on a voluntary basis and the information provided will only be used for monitoring purposes. Please do not enter any identifying marks or details on this form, so that your information remains confidential. This information will be stored on a computer.

Ethnic Origin:

Please indicate your Ethnic Origin

Asian or Asian British

Bangladeshi

Indian

Pakistani

Other

Mixed

White & Asian

White & Black African

White/Black Caribbean

Other

Other Ethnic Background

Chinese

Any Other Chinese

Other

Black or Black British

African

Caribbean

Other

White

British

Irish (Eire)

European

Other

None

I do not see my Ethnic Origin

I do not wish to disclose my Ethnic Origin

More Information:

Registered Disabled?

Yes

Sexual Orientation:

Please indicate your Sexual Orientation

Heterosexual

Bisexual

Gay

Lesbian

I do not wish to disclose my Sexual Orientation

Other

Religion or Belief:

Please indicate your Religion or Belief

Buddhist

Jewish

Hindu

Christian

Muslim

Sikh

I do not have any Religion or Beliefs

I do not wish to disclose my Religion or Belief

Other

As per Equality Act 2010:

Yes

Do you consider yourself to have a disability

Under the terms of the Act, a disability is defined as a “physical or mental impairment which has a substantial and long-term effect on a person’s ability to carry out day-to-day activities”

I do not wish to disclose whether or not I have a disability

Do You Have Caring Responsibilities:

Yes

Do you have any care responsibilities for anyone (children, elderly etc)

If yes

Children U16

Disabled

Sick / Elderly

Please answer the following questions

Do you have or have you ever had any significant health problem, impairment / disability (physical or mental) or learning difficulties that may affect your ability to undertake the tasks set out in the job description of the post offered?

Yes

Do you have or have you ever had any illness, impairment of disability that may have been caused or made worse by your work?

Yes

Have you ever left or been denied employment in an organisation on the grounds of ill health or been medically retired on the grounds of ill health?

Yes

Are you having, or waiting for any medical treatment or investigations at present?

Yes

Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?

Yes

If you answered 'yes' to any of the above questions, please provide details below:

Applicant's Declaration

Kindly select 'Yes' / 'No' as appropriate if you read and understood

I confirm that the information given above is complete and correct. I understand that any incomplete, untrue or misleading information given will entitle the employer to reject my application, withdraw any offer of employment, or, if I am employed, dismiss me without notice.(Required)

Yes

By my signature, I give authority to the employer to contact my GP for further details regarding any of the potential health problems I have declared above.(Required)

Yes

I agree that Honeydew Healthcare Ltd reserves the right to require me to undergo a medical examination to assess my suitability for work.(Required)

Yes

I do not wish to complete the questionnaire and I do not wish to have a free health assessment.(Required)

Yes

Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?(Required)

Yes

Individual Opt-out Agreement

Consent

I agree to Honeydew individual opt-out agreement

I agree with Honeydew Healthcare Limited of Eliot Park Innovation Centre, 4 Barling Way, Office EP1.5, Nuneaton,Warwickshire CV10 7RH.

(“the employer”) that the limit in regulation 4(1) of The Working Time Regulations 1998 shall not apply to me and that my average working time may therefore exceed 48 hours for each seven-day period (as defined by and calculated in accordance with The Working Time Regulations 1998).

I agree that I will comply with any and all policies of the employer, from time to time in force, which relates to its maintenance of records of my hours of work.

This agreement can be terminated by me giving three months’ notice in writing to the employer.

EMPLOYEE STARTER FORM

EMPLOYER FULL NAME: HONEYDEW HEALTHCARE LIMITED

EMPLOYEE ADDITIONAL PERSONAL DETAILS:

NI / UTR / Company Number

BANK DETAILS:

Account Name

Bank Name

Sort Code (6 digits)

Account Number (8 digits)

Applicant signature: