First name: Surname: Previous surname (if applicable ): Address (including post code ): Telephone number : Mobile: Email address: National Insurance Number: 2. REFEREES – one of these should be your present/most recent employer. If you cannot give two employer references then please provide details of someone who can provide a character reference instead. Please be aware that legislation requires us to contact all previous care employers. Please tick box if you would prefer us not to contact your referees prior to interview 1st Reference: Name: Job Title: Address: Email: Telephone: 2nd Reference: Name: Job Title: Address: Email: Telephone: 3 CURRENT / LAST EMPLOYMENT: Current/Last Job Held: Employer’s Name : Address : Dates employed : From : to : Current Salary : Have you previously worked for Care4Wales: YesNo Type of employment being sought: Full TimePart TimeRelief 4. PREVIOUS EMPLOYMENT (MOST RECENT FIRST - ADD ADDITIONAL SHEET IF NECESSARY: Please note that under Care Inspectorate Wales regulations you have to provide details of all employment since leaving compulsory education i.e. age 16 and account for any gaps (eg if you were unemployed, bringing up family, caring for family member) From (month/year): To(month/year): EMPLOYER’S NAME, DETAILS OF ROLE AND DUTIES, AND REASON FOR LEAVING: 5. EDUCATIONAL QUALIFICATIONS Qualification: Grade: Certificates available Y/N: 6. RELEVANT TRAINING UNDERTAKEN Title of training: Date: 7. FURTHER DETAILS – please give any further details that demonstrate your experience, skills or ability that make you an ideal candidate for this post 8. Welsh language – do you speak Welsh: FluentlyA littleNot at allUnderstand a little but do not speak Welsh 9. DO YOU HOLD A VALID UK DRIVING LICENCE? YES (FULL)YES PROVISIONALNO If yes how long have you been driving Do you need a work permit to work in the UK? YesNo
