01282 697535
Post applied for *
  • Full Name : *
  • Maiden name :
    Middle Name :
  • Status :
    Mr. Mrs. Miss Other
  • Address : *
    Post Code : *
  • Date of Birth :
  • Land line number :
  • Mobile number : *
  • E mail address : *
  • National Insurance number : *
  • Next of Kin:
  • Relationship:
  • Telephone number:
  • Address:
  • Please state what languages you speak:
  • Do you drive:
    Yes No

Please list in chronological order:

  • Secondary education:




Further Education



Professional qualification and training




Please list employment over the last 10 years.


Please explain any gaps in your employment history, these may be checked and any discrepancies may lead to your application not being processed:

Please give the name, address and telephone number of two professional references; one must be your last employer who is able to comment on your ability to undertake domiciliary care.

Reference Details : 1

  • Name
  • Address :
  • Post code:
  • Relationship to you:
  • Telephone number:
    Fax No:
  • Email address:

Reference Details : 2

  • Name
  • Address :
  • Post code:
  • Relationship to you:
  • Telephone number:
    Fax No:
  • Email address:

Working in the care industry entails working with the elderly and vulnerable people, what qualities do you feel you posses to fulfill the position?


Have you ever been asked to leave or been dismissed from any employment

  • Yes No
  • If yes, please give details:

Rehabilitation of Offenders Act 1974

In order to protect the public, the post for which you have applied is exempt from section 2:4 of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975, amended 1986. All convictions and cautions, conditional discharges and bind-over, no matter when imposed, must be declared.

Any information given will be completely confidential and will be considered only in relation to this application

Any information held is held under The Data Protection Act 1998

  • Signed

Pre employment medical questionnaire:

Delta Care Ltd

  • Name of GP:
  • Address of GP:
  • Telephone no of GP:

2. Occupational history:

Have you been absent from work within the last two years. If Yes please state a reason for the absence with dates.

  • Yes No

  • Please state reason:


I have read and understand each statement in this application form and agree to abide by them. I confirm that the information I have given on this application form is correct and complete, and that misleading statements may be sufficient for cancelling any agreements made. I understand that, I may be required to complete a confidential declaration in respect of my state of health. I understand that if, at a later date, it is discovered that I have knowingly withheld medical information my employment may be terminated if any information proves to be false. Because of the sensitive nature of duties I will be expected to undertake, I also understand that I am required to make a declaration which will include details of any criminal convictions, cautions, reprimands and the final warnings and any other information that may have a bearing on my suitability for the post. I understand too that an Enhanced Disclosure and check against the POVA list will be sought prior to my application being accepted. I understand that I must pay the fee for the DBS check.

I agree to inform you if any of the information I have given in this application form changes.

  • Date:
  • Sign name:
  • Please Print Name:

Delta CARE

Delta Care Ltd is one of Preston’s largest and most successful domiciliary care services offering a range of services to meet your individual care needs. We can help you with...



25 Victoria Ave,
Brierfield, BB9 5RH
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