Exordior Care – Job Application

🏷️ Ref No (Position Applied For)

Ref No

🧍 Personal Details

Nationality Address *

🗂️ Position & Availability

Position *

🏫 Current Education / Academic Status (If Applicable)

Study Mode Relevant Subjects / Modules (Optional)

🌍 Equality & Diversity Monitoring

This section is used solely for equality and diversity monitoring. It will be kept confidential and will not form part of the selection decision.

Ethnic Origin Select… Black African Black Caribbean Black Other Bangladeshi Indian Pakistani Chinese Irish White Other If Other, please specify How did you hear about this vacancy? Select… Internal External Agency Advert Job Centre Word of Mouth Other If Other, please specify

🎓 Education Background

Highest Qualification * Additional Courses / Certificates

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Education Record (Optional):

School / College / University	Qualification gained

💼 Employment History

Current Employment *

Name of employer * Job Title * Address * Duties *

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Previous Employment 2 (Optional)

Name of employer Job Title Address Duties

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Previous Employment 3 (Optional)

Name of employer Job Title Address Duties

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Employment Gaps / Time Out of Work (Last 10 Years)

Please list any periods of time not covered by your employment history (including unemployment, education, caring responsibilities, travel, sickness, volunteering, etc.). This helps us understand your timeline and does not affect your application.

Summary (optional)

Gap Details (optional): Add up to 5 gap periods.

From	To	What were you doing?	Reason / Notes

❤️‍🩹 Care Experience

Describe your relevant care experience *

⚖️ Rehabilitation of Offenders / Criminal Record

Do you have any criminal convictions? * Select… No Yes Details (if applicable)

📝 References

Please provide three professional references; one should be your current/most recent employer where possible.

Reference 1 *

Name * Establishment / Organisation * Address

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Reference 2 *

Name * Establishment / Organisation * Address

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Reference 3 (Optional)

Name Establishment / Organisation Address

📌 Employment History Declaration

Select one * Select… I am NOT under investigation/suspension and have never been dismissed I am currently / previously under investigation, suspension or have been dismissed If applicable, provide details

☎️ Emergency Contact / Next of Kin

Emergency Contact 1

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Emergency Contact 2

🏦 Payment Authorisation / Bank Details

Address

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Bank / Building Society Address

📚 Evidence of Professional Qualifications / Mandatory Training

Details

🩺 Health Questionnaire

Select Yes/No for each item.

Condition	Yes / No
Psychiatric Illness / Anxiety / Depression	Select… Yes No
Headaches / Migraine	Select… Yes No
Heart Problems / Circulatory Illness / Hypertension	Select… Yes No
High or Low Blood Pressure	Select… Yes No
HIV	Select… Yes No
Dermatitis / Skin Sensitivity / Psoriasis / Eczema / Allergies	Select… Yes No
Diabetes	Select… Yes No
Asthma / Hay fever	Select… Yes No
Typhoid	Select… Yes No
Bronchitis / Pneumonia / Pleurisy	Select… Yes No
Tuberculosis	Select… Yes No
Epilepsy / Fainting / Blackouts / Fits / Sudden Collapse	Select… Yes No
Back Injury / Back Problems / Back Pains	Select… Yes No
Recurrent Infections (Sore throats / Ear / Eye infections etc.)	Select… Yes No
Hepatitis / Jaundice	Select… Yes No
Tetanus	Select… Yes No

Additional Notes (Optional)

📜 Declarations

1. Health Declaration I confirm that the information I have provided regarding my health is true and complete to the best of my knowledge. I understand that, where appropriate and with my consent, my GP or an Occupational Health provider may be contacted to confirm my fitness for the role. I agree to notify Exordior Care of any change in my health that may affect my ability to safely perform duties within this role.

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2. Terms and Conditions I confirm that I have read, understood, and agree to comply with Exordior Care’s terms and conditions of engagement, policies and procedures, including but not limited to safeguarding, confidentiality, professional conduct, and data protection. I understand that failure to comply may result in disciplinary action and/or termination of engagement.

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3. Induction I confirm that I will complete all required induction activities and mandatory training, and that I will work in accordance with Exordior Care’s standards, policies, and procedures. I understand that I must seek guidance when unsure and escalate concerns promptly to ensure safe practice.

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4. Working Time Regulations I understand the Working Time Regulations and confirm that I will work within safe limits, take appropriate rest breaks, and accurately report working hours. I agree to notify Exordior Care if I undertake additional employment that may affect compliance, fatigue, or safe working.

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5. Bank Details Declaration I confirm that the bank details I have provided are accurate and belong to me (or I am authorised to use them). I understand that Exordior Care is not responsible for payment delays or losses arising from incorrect information supplied by me, and I agree to notify Exordior Care immediately if my bank details change.

🔐 Data Protection

I understand that Exordior Care will process my personal data for recruitment, compliance, safeguarding, payroll and related administrative purposes, in accordance with UK GDPR and the Data Protection Act 2018. I understand that information may be shared with relevant third parties where necessary (e.g., for DBS checks, right-to-work verification, training compliance, and reference checks). I confirm that the information I provide is accurate and I consent to it being processed for these purposes.

✅ Final Declaration

I declare that the information I have provided in this application is true, complete, and accurate. I understand that providing false or misleading information may result in the withdrawal of my application or termination of employment.

I understand that Exordior Care is committed to safeguarding vulnerable adults, and I agree to follow all safeguarding policies, procedures, and reporting duties.

I consent to my personal data being processed for recruitment, compliance, and safeguarding purposes in accordance with GDPR. I understand that employment is subject to satisfactory checks including references, right-to-work, and a DBS check.

📄 Pre-Filled Form Upload

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📎 Supporting Documents

ID Document Proof of Address (1) Proof of Address (2) Training Certificates Other Documents