Employment Application Form

179 - 181 Weedon Road
Tel : 01604 753104 Fax : 01604 750760

The following information will be treated in the strictest confidence.

(All staff will be required to produce evidence of nationality and entitlement to work within the United kingdom in accordance with current legislation. A failure to produce the relevant evidence will result in the withdrawal of any employment offer. The provision of false information will result in suitable action being taken that could lead to the termination of your employment)

The Care Standards Act 2000 and all subsequent legislation requires that all employees have a clear Vulnerable Adults, Children & Police Check. The information contained in this check will be registered with the Disclosure and Barring Service. If offered the position, the check will be organised by us but a charge to do this will have to be paid by you. This will be discussed with you during your interview. The CRB Check will have to be validated every three years, the charge for which will have to be paid by you. This will still apply even if you already possess an up to date CRB clearance and you must bring it to the interview.

Overall State of Health:
SpectacleContact LensesNeither
Do you wear any of the following:
Higher education
(or last Employer if currently unemployed)
Employment Dates
(per week/month/annum)

List all Previous Employment.(Employer Name, Address and your Job Title)


You must provide names of two referees, who must not be family members, one of whom must be your current or last employer. References may be taken up prior to interview.


The nature of the work you will be asked to undertake means it is exempt from the provisions of the Rehabilitation of Offenders legislation. This means that you must provide us will all information relating to any form of conviction at any time in your lifetime. This includes such matters as police cautions, anti social behaviour orders or informal warnings as well as any other form of conviction whether you were sent to prison or not. You are not entitled to withhold any information whether the sentence is spent or not. Any information will be completely confidential and will only be considered in relation to the post that you are applying for. A criminal record in itself may not be a bar to obtaining employment.

If you have been registered on the list relating to vulnerable adults or children and your registration has been confirmed you should be aware that you would be committing a criminal offence in applying for a post in a care position.

Any failure to notify of any form of conviction or any other form of misleading or false information now or at any time in the future could result in disciplinary action that could lead to the termination of your employment at any time during the course of your employment.

It is a requirement that a Criminal Records Bureau check, which includes a check against the Vulnerable Adults and Children’s registers, must be carried out and by signing this declaration you agree to this being carried out.

I declare the above information to be true and I understand that providing false information would lead to my employment being terminated immediately.

Please add any additional information to support your application.

If offered the position it will be a requirement of your employment for you to provide copies of the following documentation that you may hold: Passport, Birth certificate, Marriage certificate, change of name certificate, visa, work permit, driving licence, qualifications obtained and any other documentation that may be requested. A recent photograph will also be required.

I confirm that the information I have provided is correct and understand that misleading statements may be sufficient grounds for cancelling any agreements made. I also understand that questions left unanswered may be discussed at interview(s) arising from this application. I also agree to the Criminal Record Bureau checks being carried out and to pay for the charges in doing so. I understand that, if offered a position, my employment is subject to satisfactory Criminal Record Bureau & Disclosure & Barring Service checks and references.

Current Care Shift Patterns:

Prep 7.00 a.m. – 10.00 a.m. no break
Early 7.00 a.m. – 2.00 p.m. ¼ hr break
Late 1.45 p.m. – 8.00 p.m. ¼ hr break
Long Day 7.45 a.m. – 8.00 p.m. ¼ hr break am & pm
½ hr lunch break
Nights 7.45 p.m. – 8.00 a.m. ¾ hr break

Current Housekeeper Shift Patterns:

Five days per week from 9.00am to 6.00pm and working alternate weekends.

Current Kitchen Shift Patterns:

Five days per week from 7.45am to 6.00pm and working alternate weekends with 1 hr break.

Attendance Bonus paid per hour to all staff subject to scheme rules.

The Company will provide uniforms, 5.6 weeks pro rata paid annual leave and statutory sick pay.

All posts include weekend & bank holiday working.

Policy Statement on the Recruitment of Ex-offenders

As an organisation using the Criminal Records Bureau (CRB) Disclosure Service to assess applicants’ suitability for positions of trust, Glenside Care home Ltd trading as Glenside Residential Care Home (Glenside) complies fully with the CRB Code of Practice and undertakes to treat all applicants for positions fairly. It undertakes not to discriminate unfairly against any subject of a Disclosure on the basis of a conviction or other information revealed.

Glenside is committed to the fair treatment of its staff, potential staff or users of its services, regardless of race, gender, religion, sexual orientation, responsibilities for dependants, age, physical/mental disability or offending background.

This written policy on the recruitment of ex-offenders is made available to all Disclosure applicants at the outset of the recruitment process.

We actively promote equality of opportunity for all with the right mix of talents, skills and potential and welcome applications from a wide range of candidates, including those with criminal records. We select all candidates based on their skills, qualifications and experience.

A Disclosure is required for all positions and all applications, job adverts and recruitment briefs will contain a statement that a Disclosure will be requested in the event of the individual being offered the position.

As the Disclosure is to form part of the recruitment process, we encourage all applicants called for an interview to provide details of their criminal record and any possible convictions at an early stage in the application process. We request that this information is sent in an envelope marked private and confidential for the attention of the manager at Glenside and we guarantee that this information will only be seen by those who need to see it as part of the recruitment process. You can also, if you wish, provide details at an interview if you are called to one.

The nature of positions at Glenside allows us to ask questions about your entire criminal record and also about unspent convictions as defined in the Rehabilitation of Offenders Act 1974.

We ensure that all those at Glenside who are involved in the recruitment process have been suitability trained to identify and assess the relevance and circumstances of offences. We also ensure that they have received the appropriate guidance in the relevant legislation relating to the employment of ex-offenders.

At interview, or in a separate discussion, we ensure that an open and measured discussion takes place on the subject of any offences or other matters that may be relevant to the position. Failure to reveal information that is directly relevant to the position sought could lead to withdrawal of an offer of employment.

We make every subject of a CRB Disclosure aware of the existence of the CRB Code of Practice and make a copy available on request.

We undertake to discuss any matter revealed in a Disclosure with the person seeking the position before withdrawing a conditional offer of employment.

Having a criminal record will not necessarily bar you from working with us. This will depend on the nature of the position and the circumstances and background of your offences.

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Contact Us

Glenside Care Home tries to offer its residents a home from home atmosphere in spacious and peaceful surroundings. Residents are encouraged to use the facilities and the patio and gardens as they wish.

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