Application Form for Companion - Caregiver

IMPORTANT INFORMATION!

Before you complete this Form:

1)    All applicants must be in the UK

2)    You must have spoken to Norma Lewis on 07956 89 45 89

3)    Your will need to have your papers ready

Some photos of yourself – happy smiling ones, as no Family will want an unhappy companion/caregiver in their home!
Proof of ID ( Passport / ID Card)
2 References in writing. (Not from Friends or Family Members)
Any relevant Certificates ( NVQ / Cooking / First Aid)
Driving Licence (If applicable)
CV, giving details of your Work History / Placements, and what your duties were. Please explain any gaps in employment.
CRB / Police Check Certificate. A Disclosure will be requested in the event of an individual being offered a position.

Please email the information to norma@normalewisdomesticstaff.co.uk . Let me know if you have any problems with any of your Papers, so that I can try to help you.

Do you have your documents ready * Yes
No

Personal Details

Surname *

First Names *

Address *

Town/Country *

Post / Zip Code *

Home telephone number

Mobile telephone number *

Email address *

Emergency contact name *

Relationship to you

Emergency contact number *

Date of birth *

Age *

Place of birth *

Nationality *

Gender * Female
Male

Passport ID number *

Passport date of issue *

Passport date of expiry (Please enter not applicable if you do not have a passport) *

Is visa work permit necessary? *

Marital Status * Single
Married
Divorced
Widowed

Do you have any children? * Yes
No

If so how old are they

Position Required

Are you looking for a position that is * Long Term
Short Term
Either

Are you looking for a job that is * Live In
Live Out
Either

Minimum length of job required *

Maximum length of job required *

Available to start from *

Minimum salary accepted per week or per hour (NET) *

Are you happy to help with personal care such as washing and dressing * For a man
For a woman
Either

Are you happy to do housework as part of the job * Yes
No

Are you happy to cook as part of the job * Yes
No

Will you travel with the person if required Yes
No

Do you have any visa / passport restrictions on travel? Yes
No

What are these restrictions?

Do you speak any other languages?

Are you happy to live with a person with pets Yes
No

Are there any animals you really dislike?

Would you help with pets as part of your job? Yes
No

Are you happy to live with a person with a different religion to my own Yes
No

Your Qualifications and Experience

Your level of education, NVQ

Have you been a companion carer previously Yes
No

Your present occupation duties in brief and current salary

(IN ADDITION, PLEASE ATTACH A FULL CV / JOB HISTORY. YOU NEED TO EXPLAIN IN DETAIL ANY PREVIOUS EXPERIENCE OF CARING THAT YOU HAVE).

Driving

Do you have a current, full driving licence? * Yes
No

Is it valid for driving in the UK * Yes
No

Have you driven in the UK Yes
No

Do you have any points or endorsements? Yes
No

If so, how many and for what?

Can you drive a car that is Manual

Do you have your own car? * Yes
No

More Details

Are you under medical treatment for any condition? Please explain

Do you have any allergies? If so, to what, and to what extent?

Are you vegetarian? Yes
No

If yes, would you work with a family who was not vegetarian? and cook meat and fish for them Yes
No

If no, would you work with a family who was? Yes
No

Are there any foods you never eat?

Do you smoke? Yes
No

How many per day?

Are you prepared to promise that you will not smoke in the house Yes
No

Do you have a criminal record Yes
No

(This is an exempted position under the Rehabilitation of Offenders Act 1974, and therefore information is required with regards to both spent and current convictions. Please send any relevant information by separate cover, in confidence, to Norma Lewis, at norma@normalewisdomesticstaff.co.uk

This information will only be seen by those who need to see it as part of the recruitment process.)

And Finally...

Do you have any knowledge of First Aid

Would you like information on First Aid courses Yes
No

How did you hear of this agency? *

What other agencies have you contacted?

SUBMITTING THIS FORM IN ANY FORMAT TO THE NORMA LEWIS DOMESTIC STAFF AGENCY SHOWS THAT YOU HAVE READ, UNDERSTOOD, AND ACCEPTED THE FOLLOWING DECLARATION, AND WILL ABIDE BY IT.
IF DOWNLOADED, THIS DECLARATION IS TO BE SIGNED IN DUPLICATE, 1 COPY FOR NORMA LEWIS, AND 1 FOR THE APPLICANT:

I DECLARE THAT TO THE BEST OF MY KNOWLEDGE, ALL THE ABOVE INFORMATION IS CORRECT AND TRUE. SHOULD ANY INFORMATION CHANGE, I WILL NOTIFY NORMA LEWIS AGENCY IMMEDIATELY.
ONCE I HAVE BEEN OFFERED A POSITION, AND AFTER I HAVE ACCEPTED, I WILL NOTIFY THE AGENCY IMMEDIATELY.
I WILL NOT START MY NEW POSITION UNTIL AFTER I HAVE RECEIVED MY CONFIRMATION OF PLACEMENT FROM THE AGENCY.
I WILL PAY FOR ANY TELEPHONE BILLS INCURRED DURING MY PLACEMENT AS A COMPANION / CARER
IF I AM UNHAPPY AND WISH TO LEAVE MY PLACEMENT I WILL TELEPHONE NORMA LEWIS. (TELEPHONE 0208 950 8611, MOBILE 07956 894589).
I WILL HAND IN A MINIMUM OF 14 DAY'S NOTICE TO THE FAMILY.
I UNDERSTAND THAT I CAN BE GIVEN NOTICE, OR SUMMARILY DISMISSED IF:
1. I FAIL TO ABIDE BY THIS AGREEMENT
2. I HAVE GIVEN FALSE INFORMATION ON MY APPLICATION FORM
3. I START MY PLACEMENT BEFORE RECEIVING MY OFFICIAL CONFIRMATION FROM THE AGENCY.
4. I BREAK THE LAW, OR ACT IN A WAY THAT ENDANGERS ANY PERSON IN MY CARE.

Name *

Date *

GENERAL INFORMATION

Home

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What Is An Au Pair? (ECAPS Guidelines)

Important Legal Information For Employers

What Is A Nanny, Mother's Help, Housekeeper And Companion Carer

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FOR APPLICANTS

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Advice To A New Au Pair

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Nannies/Mother's Helps Application Form

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Application Form for Companion Caregiver

FOR FAMILIES

How I Can Help Families

Care For the Elderly Person

Family Registration Form for an Au Pair

Family Registration Form For A Nanny, Mother's Help (Live In / Out)

Family Registration Form For A Housekeeper

Family Reg Form For Companion Caregiver

Terms

Fees

Application Form for Companion - Caregiver

IMPORTANT INFORMATION!

Before you complete this Form:

1)    All applicants must be in the UK

2)    You must have spoken to Norma Lewis on 07956 89 45 89

3)    Your will need to have your papers ready

Personal Details

Position Required

Your Qualifications and Experience

Driving

More Details

And Finally...

GENERAL INFORMATION

FOR APPLICANTS

FOR FAMILIES

Application Form for Companion - Caregiver

IMPORTANT INFORMATION!

Before you complete this Form: 1) All applicants must be in the UK 2) You must have spoken to Norma Lewis on 07956 89 45 89 3) Your will need to have your papers ready

Personal Details

Position Required

Your Qualifications and Experience

Driving

More Details

And Finally...

Before you complete this Form:

1) All applicants must be in the UK

2) You must have spoken to Norma Lewis on 07956 89 45 89

3) Your will need to have your papers ready