PLEASE PROVIDE THE FOLLOWING DOCUMENTATIONS FOR THE OFFICE WHEN BRINGING IN YOUR COMPLETED
APPLICATION FORM:
Fully completed Application Form (including all details for 2 references, names, email addresses and telephone
numbers for the office to contact)
If you cannot provide 2 WORK REFERENCES, please fill in the form titled ‘Recruitment Further Investigation Record’
and fill in section under ‘References’ giving reason why (for example: only arrived in the UK/have only had one job)
Payment for DBS (£52) + Online Register Service (£13) - (The Online Register Service can be completed once you receive
back your DBS Certificate. This needs to be completed within 27 days of receiving your DBS. After registering for the
Online Register Service, you only need to pay £13 a year)
IF YOU HAVE A HOLIDAY BOOKED FROM YOU PREVIOUS EMPLOYMENT YOU MUST LET US KNOW, please complete
the attached holiday form & pass onto the office staff
Signed GDPR (provided by the office for you to sign)
2 x Proof of addresses
Proof of National Insurance Number
Driving License / Passport / ID Card (please provide at least 2)
Regional Care Cambridge Page: 1 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
PE2 6XU, 01733 838380
Application Form
PLEASE ENSURE YOU COMPLETE THE APPLICATION FORM IN FULL as we cannot accept CVs. Please complete
PR12
with black ink and block capitals. This form will be kept in confidence.
Please note that no applicant will be unfairly discriminated against. This includes discrimination on account of
age, cultural/religious/political belief, disability, ethnicity, gender, race, relationship status, sexual orientation,
and/or Trade Union membership or stewardship.
If you have any special requirements to support you to complete this form (e.g. the need for large print
or additional time) please contact the Registered Manager on 01733 838380.
Position
Position applied for: Assistant Career Nurse
Preferred employment type (e.g. part time, full Full Time
time):
Personal Details
Surname: Begum First name(s): Yeasmin Title (Mr/Mrs/Miss/Ms)
Current Address: Vill: Mazgaw, P.O: Singerkatch Postcode: 3134
Bazar-3134, P.S: Bishwanath, Sylhet
Date moved in:
Telephone number (home): Telephone number (mobile): +880 1767660266
Email address: Yeasminbegum051996@[Link]
Own Transport How long has your license been held?
Yes/No
Further Details:
Are you a United Kingdom (UK), European National Insurance Number:
Community (EC) or European Economic Area
(EEA) National (please circle)? Date of Birth:
YES / NO*
Are you are related to a member of staff or Service User
If no, please detail current immigration status and at RegionalCare, please circle only:
the relevant visa currently held (including Visa
number): YES / NO*
Equality Act 2010
Under the Equality Act 2010 the definition of disability is if you have a physical or mental impairment that has a
'substantial' and 'long-term' adverse effect on your ability to carry out normal day to day activities. Further
information regarding the definition of disability can be found at: [Link]/definition-of-disability-under-equality-
act-2010
Reasonable adjustments will be made available should you be invited to interview. According to the definition of
disability do you consider yourself to have a disability?
YES / NO / Prefer not to discuss
Regional Care Cambridge Page: 2 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
PE2 6XU, 01733 838380
Application Form
PR12
Education
Examinations Passed, Qualifications Gained and year obtained
School/College/University
(All qualifications will be subject to a satisfactory check).
Singer Kach Public Bohu Mukhi Secondary School Certificate (SSC) 2012, (3.88 out of 5.00)
High School
Bishwanath College Higher Secondary Certificate (HSC) 2014, (3.70 out of 5.00)
Sylhet Govt. Women’s College Bachelor of Arts (B.A) 2017, (2.70 out of 5.00)
Training Courses Attended Or Completing
Subject
(evidence of attending courses is Location/Details Date
required)
Care Assistant Al Falah Hospital 05-07-2021 to 28-02-2023
Regional Care Cambridge Page: 3 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
PE2 6XU, 01733 838380
Application Form
PR12
Employment History: Please record below the details of your full employment history beginning with your
current or most recent first. Use a separate attached sheet if required; please sign the sheet(s).
Name and address of your most Al-Falah Hospital, Dorgah Gate, Amberkhana, Sylhet
recent/last employer:
Start date and end date: 05-07-2021 to 28-02-2023
Nature of business: Care Assistant
Position held and reason for leaving:
Salary / Rate: 15,000
Name and address of employer
prior to the employer listed above:
Start date and end date:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Name and address of employer
prior to the employer listed above:
Start date and end date:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Regional Care Cambridge Page: 4 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
PE2 6XU, 01733 838380
Application Form
PR12
Name and address of employer
prior to the employer listed above:
Start date and end date:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Please detail here any gaps in employment and state why:
Regional Care Cambridge Page: 5 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
PE2 6XU, 01733 838380
Application Form
PR12
Supporting Statement
We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By
signing this application form, you consent to us holding the information contained within this application
form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would
like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will
consider this period over when a candidate accepts our job offer for the position for which we are
considering you). When that period is over, we will either delete your data or inform you that we would like to
keep it in our database for future roles.
We have privacy policies that you can request for further information. Please be assured that your data will
be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant
post.
You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw
consent and to be kept informed about the processing of your data. If you would like to discuss this further or
withdraw your consent at any time, please contact the Registered Manager to discuss.
Regional Care Cambridge Page: 6 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
PE2 6XU, 01733 838380
Application Form
PR12
MANDATORY WORK REFERENCES:
You must provide references from your two most recent employers. Please provide 1 character
references if you are unable to obtain two professional references, e.g. in the case of an applicant
who has been raising children for ten years. All will be contacted, therefore please inform the referees of
the fact that you have used their name. If you are unable to provide the required references, please
discuss the matter with us and complete the form titled ‘Recruitment Further Investigation Record’ under
‘References’.
Current or Most Recent Employer
Name:
Address:
Postcode:
Tel No: Email address:
Job title:
Previous Employer To The One Above
Name:
Address:
Postcode:
Tel No: Email address:
Job title:
Regional Care Cambridge Page: 7 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
PE2 6XU, 01733 838380
Application Form
PR12
PLEASE PROVIDE 1 CHARACTER REFERENCE (if you cannot provide 2 work references)
Character Reference (1)
Name: Syed Tahmid Siddiki
Address:
Postcode:
Tel No: 01303673247 Email address: syedtahmid084@[Link]
Relationship to you:
Regional Care Cambridge Page: 8 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
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ALL INFORMATION IS REQUIRED ON THIS PAGE
Application Form
PR12
Previous Addresses:
Please provide 5 years worth of addresses:
1. Your Current Address: Rohimpur, Islamabad-3088, Bishwanath, Sylhet
Date moved in (From): 5th May 2023 (To): till now
2. Previous Address: Mazgaw, Singerkatch Bazar, Bishwanath, Sylhet
Date moved in (From):5th January 2019 (To): 4th May 2023
3. Previous Address: …………………………………………………………………………………………....
Date moved in (From): ……………………………….. (To): …………………………………………
Your work preferences (please state below hours and days that you can offer):
PART TIME: FULL TIME:
*
Monday: DAYS:10.00 AM:6.0 PM
Tuesday: DAYS: 10.00 AM:6.0 PM
Wednesday: DAYS: 10.00 AM:6.0 PM
Thursday: DAYS: 10.00 AM:6.0 PM
Friday: DAYS:……. AM:……..PM
Saturday: DAYS: 10.00 AM:6.0 PM
Sunday: DAYS: 10.00 AM:6.0 PM
YOUR UNIFORM SIZE (for example, size 10, 12, 14, 18, 20):………………………………………….
Bank Details:
Bank Name: ………………………………………….
Account Number: …………………………………………..
Sort Code: …………………………………………..
Name on the Account: …………………………………………..
VERY IMPORTANT: would you like to be paid PAYE or SELF EMPLOYED?…………………
Next of Kin Details:
Please provide a name and contact number of a next of kin.
Name: Md Abdul Malik
Relationship to you: Husband
Contact number:+880 1834733927
If married please give previous surname & date you got married:
………………………………………………………………………………………………
Date name changed: ……………………………………………………………………
Regional Care Cambridge Page: 9 of 10
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, Issued:15/1/2020
PE2 6XU, 01733 838380
Application Form
Safeguarding PR12
Ex-Offenders Declaration
Please note this section will only be seen by those involved in the recruitment process and will be treated with the
strictest of confidence.
Rehabilitation of Offenders Act 1974
RegionalCare aims to promote equality of opportunity and is committed to treating all applicants fairly
regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation,
pregnancy or maternity and marriage or civil partnership. RegionalCare undertakes not to discriminate unfairly
against applicants on the basis of a criminal conviction or other information declared.
Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the
relevance of the information you provide in respect of the nature of the position and the particular circumstances.
Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a
Court or Court-Martial in the United Kingdom or in any other country?
YES* NO
Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in
any other country?
YES* NO
Privacy
RegionalCare will only collect data for specified, explicit and legitimate use in relation to the recruitment process.
By signing this application form you consent to RegionalCare holding the information contained within this
application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We
would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will
consider this period over when a candidate accepts our job offer for the position for which we are considering
you). When that period is over, we will either delete your data or inform you that we would like to keep it in our
database for future roles. We have privacy policies that you can request for further information. Please be
assured your data will be securely stored by the Registered Manager and only used for the purposes of
recruiting for this vacant post. You have a right for your data to be forgotten, to rectify or access data, to restrict
processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to
discuss this further or withdraw your consent at any time please contact the Registered Manager or Privacy
Officer on 01733 475517.
Declaration
The information in this application form is true and complete. I agree that any deliberate omission, falsification or
misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if
employed by RegionalCare. Where applicable, I consent that RegionalCare can seek clarification regarding
professional registration details.
Name: Miss Yeasmin Begum Date: 03/11/2023
Signature
Regional Care Cambridge Page: 10 of
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, 10
PE2 6XU, 01733 838380
Application Form
PR12
CARER STANDARD QUESTIONS:
In order to guild the interview process, we would like you to indicate your personal philosophy of Care by completing the
following statement. Please ensure all boxes are filled out.
I believe that the purpose of care
from a care service is:
If I were a service user in
Regional Care,
What kind of care would you like
to receive:
What do you think the service
user’s family and relatives would
like from Regional Care:
How can a service user provide
regional care with feedback about
the service:
As a carer for regional care
working in a team I feel valued
when:
I believe a good relationship
between me and the service user
depends on:
I believe that I learn best when:
I believe that a team that is
working together well is made up
by:
I believe that my role in relation to
the service user is:
I believe that Care should be
delivered in a way that is:
Regional Care Cambridge Page: 11 of
Unit 4 Orton Enterprise Centre, Bakewell Road, Peterborough, 10
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Application Form
PR12
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