Application form 1Personal details2Education3CPD4Professional bodies5Personal qualities6Present employment7Previous employment8Breaks in employment9Criminal record10References11Marketing12Declaration13Preview form submission Post Applied for Reference number Closing date Interview date Section 1: Personal DetailsName* First name(s) Last name Address Street Address Address Line 2 Town/City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home telephone numberMobile telephone numberBusiness telephone numberCan we contact you at work? Yes No Email address* Do you have a bank account? Yes No Are you free to remain and take up employment in the UK with no current immigration restrictions? Yes No Do you hold a full driving licence valid in the UK? Yes No What type of driving license do you hold? Auto Manual Do you have regular access to a car? Yes No Do you have any endorsments on your licence? Yes No Please give further details, including datesIf appointed, do you have any interests or hold any appointments that may conflict with employment by Potential Living in the role for which you have applied? Yes No If yes please give full detailsWhat type of employment would you consider? Bank Full time Part time Are you willing to work overtime if required?You will be required to work at the times the person needs their service. This could include daytime, afternoons, evenings and weekends. Overnight support could include waking or sleeping. Yes No Are these any specific times you would not be able to work?Please give full details.Have you ever worked for this company before? Yes No If Yes, what was your reason for leaving?Have you applied for employment with this company before? Yes No Are you related to or do you know any person employed by this company? Yes No If Yes, please give full detailsNameRelationship to you Use the button if you need to add more rows. Section 2: EducationPlease list any qualifications obtained from schools, colleges and universities. Please list highest qualification first.Please note: if your application is sucessful you must provide evidence of any qualifications listed in the form of the original certificate(s). These will be returned to you in their original state once processed.Use the button if you need to add more rows.Training Provider, College or UniversityCourseQualifications and grades obtainedAwarding body Use the button if you need to add more rows.Use the button if you need to add more rows.SchoolSubjectsQualifications and grades obtained Use the button if you need to add more rows. Section 3: Continued Professional DevelopmentPlease give details of any learning and development courses or non-qualification courses which support your application. Include any on-the-job training as well as formal courses.Use the button if you need to add more rows.Type of development (eg training course, conference, etc)Certificate issued by (eg employer, REHIS, etc)Duration of course Use the button if you need to add more rows. Section 4: Membership of Professional & Regulatory BodiesPlease list memberships for professional bodies eg Scottish Social Services Council (SSSC), Nursing and Midwifery Council (NMC), any group regulated by the Health Professions Council, etc. Please note: If your application is successful you must provide evidence of any professional memberships listed in the form of the original documentation. This will be returned to you in its original state once approved. If you application is successful periodic checks throughout your employment will be carried out to ensure registration with the relevant body is up-to-date. Keeping your registration up-to-date will be a condition of employment in line with Scottish Social Services Council (SSSC) guidance. If you are successful you will be required to provide your registration number prior to commencing employment.Use the button if you need to add more rows.Professional Body (eg SSSC, NMC, HPC, etc)Date first registeredFrequency of renewalRegistration expiry date Use the button if you need to add more rows.Are you subject to any type of disciplinary action(s) by a professional or regulatory body such as SSSC, NMC, etc? Yes No If yes, please give full details Section 5: Personal Qualities and Transferable SkillsThe make up of the teams supporting the people we work for is the key to the success of their support. We place a great deal of emphasis on getting the right person for the job. Please answer the following questions to help us find a suitable match for you.How would you describe yourself?What experiences and knowledge do you have that you could apply to the post and how would you do it?Please refer to the Job Description.What qualities would you bring that would enhance the individual's life / their team / Potential Living?Please list your interests, leisure activites, etceg hobbies, sports, club memberships, etcSupplementary informationPlease set out below any further information to support your application, eg past achievements, future aspirations, personal strengths. Section 6: Present EmploymentAre you: Currently Employed Currently Unemployed If you are unemployed, please list the details of your most recent employer below.Name of Employer Address Street Address Address Line 2 Town/City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Salary (£) Job title Department / Section Employed from DD slash MM slash YYYY Employed to DD slash MM slash YYYY Brief description of dutiesPeriod of notice required Reason for leaving Reason you wish to leave Section 7: Previous EmploymentPlease list your previous employers, starting with the most recent first.Use the button to add more rows.Name of employerNature of employer's businessDates worked (from/to)Position held / Main dutiesReason for leaving Use the button to add more rows. Section 8: Breaks in employment historyPlease list any times where you have been out of work eg attending college, redundancy, etcUse the button to add more rows.FromToReason Use the button to add more rows. Section 9: Criminal recordCandidates are required to disclose any unspent convictions or cautions and any spent convictions for offences included in Schedule A1, ‘OFFENCES WHICH MUST ALWAYS BE DISCLOSED’ of the Rehabilitation of Offenders Act (Exclusions and Exceptions) (Scotland) Amendment Order 2105. Candidates are not required to disclose spent convictions for offences included in Schedule B1, ‘OFFENCES WHICH ARE TO BE DISCLOSED SUBJECT TO RULES’ until such time as they are included in a higher level disclosure issued by Disclosure Scotland.Do you have any convictions? Yes No Please give dates and details of offences and sentencesDatesNature of offence / charge / caution / binding over order / dischargeSentence, penalty or order Have you lived in the UK for the last 5 years? Yes No If No, please note that you will be required to provide evidence from your previous country of residence as to whether you have any criminal convictions in that country.Please give details of any current investigation(s) or pending court case(s) that might affect your ability to do this job.Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Section 10: ReferencesWe require 2 references, 1 of which MUST be your present employer (or most recent employer if you are unemployed). This reference should be from a member of your organisation's management team. References will only be sought on candidates who are successful at interview. We cannot accept references from family members or relatives. If you have been in full-time education, and have never been employed, we will accept two academic referees in place of an employer. If you have been unemployed for a long period of time (6 years or more) and your last employer no longer has your employment records, you can give two character references from individuals who are unrelated to you eg GP, reverend, priest, your local councillor, etc. If you do not provide this information your application cannot be processed.Reference 1Name* First Last Organisation / Company Position Job titleRelationship Professional Academic Character Address Street Address Address Line 2 Town/City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TelephoneEmail Reference 2Name* First Last Organisation / Company Position Job titleRelationship Professional Academic Character Address Street Address Address Line 2 Town/City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TelephoneEmail Section 11: Marketing SourceHow did you hear of this vacancy?Local press Bellshill Speaker Hamliton Advertiser Lanark and Carluke Advertiser Motherwell Times Wishaw Press Associated Newspapers Third Force News Facebook Indeed Other Potential Living flyer advert General enquiry Internal applicant Jobcentre Plus Potential Living website Word of mouth Section 12: DeclarationI hereby certify that: All the information given by me on this form is correct to the best of my knowledge All questions relating to me have been accurately and fully answered I possess all the qualifications which I claim to hold Successful candidates will be required to provide relevant evidence of details contained within this application prior to appointment, eg driving licence, certificates, immigration information, etc. Data Protection Notice: the Company requires certain information prior to you commencing employment, to ensure you will be able to perform the requirements of the job and give reliable service, and to ensure compliance with relevant Health and safety regulations. The information is also required in order to establish whether any reasonable adjustments may need to be made to assist you in performing your duties, in accordance with the Disability Discrimination Act 1995. The information you provide will be treated in the strictest confidence, and used only for the purposes detailed above in compliance with the Data Protection Act 1998.Signed Reset signature Signature locked. Reset to sign again Date DD slash MM slash YYYY NB Candidates selected for interview will normally be notified within three weeks of the closing date. Unfortunately applicants who do not hear from Potential Living must conclude that their application has been unsuccessful on this occasion. Preview your form submission{all_fields}CommentsThis field is for validation purposes and should be left unchanged.