B&M CARE

Application for Employment Form C4-005

Private & Confidential

Job applied for: Job ref: ………………...

Care Assistant

We are committed to promoting the equality of opportunity and welcome applications from
anyone who feels that they are able to carry out the duties, regardless of any previous experience.

Please tell us about yourself

First name: Valeriia If under 21 years old, please
give your Date of Birth:
Other names: ……………………….……………………

Surname: Danylchuk
Home address: 69 Codicote road

Postcode: AL69TY
Home tel. no: Work tel. no:.
Mobile tel.no 07442263953
Email Address: lerik.nikityuk@gmail.com

May we ring you at work? YES Are you related to any present or former
employees of the home? NO
How did you find out about this vacancy?
Google
Please give us the details of two previous employers who will provide us with a reference. One
must be your most current / recent employer and the second from your previous employment
prior to your current / recent employer If this is not the case, please tell us why not. We will not
contact your employer before an interview, but we will contact them before appointment.

Name: Oksana Zinchenko Name: Volodymyr Nemertsalov

Position: PhD, Associate Professor. Position: PhD, Associate Professor, Professor of the
Organisation: Department of teaching methods and content
Address: Shampansky lane , 2 education.....................................................................
Organisation: ..............................................................
..................................................................................... Address: Mykhailivska square, 17..............................
Postcode: .................................................................... .....................................................................................
Tel. no. work: ............................................................. .....................................................................................
Tel. no. other: ............................................................. Postcode: ....................................................................
Is this your current employer? NO Tel. no. work: .............................................................
(If current employer, do you agree to obtain Tel. no. other: .............................................................
reference prior to interview? Is this your current employer? NO
Are they related to you? NO (If current employer, do you agree to obtain
Email Address: ozinchenko@gmail.com reference prior to interview?

Are they related to you? NO

Email Address: nemertsalov@gmail.com

Issue No: 3 Rev: 3 Issue Date: April 2022 Approved by: ……………………………… Page 1 of 6
© Bettal Quality Consultancy Cared 4 2011
In association with B&M CARE
 B&M CARE
Application for Employment Form C4-005
Please tell us about your education and training
Please tell us about your education. List any qualifications gained.

School / College From To Qualifications –

include dates and grades
Odesa National 2016 2017 Biology Professional Qualification
University Microbiologist Master of Science
I.I.Mechnikov
Odesa National 2012 2016 Bachelors : engineer-laboratory assistant in
University the field of Biology and Chemistry, school
I.I.Mechnikov teacher of Biology and Chemistry

If you have undertaken any training or voluntary work to improve your employment
prospects, please give details below:

Please tell us about jobs you have had

Please tell us about your full history of employment starting with your present, or most
recent, job first. Please ensure you list all previous employment & give reasons for your gaps
in employment; failure to provide this information or to omit any of your previous employers
could be considered as an act of gross misconduct.
Employer Job title and From To Reason for Reason for gap
description of duties leaving in employment
Feb. Feb. the war in
Sanitary- Biologist, microbiologist 2022 2022 Ukraine
epidemiologi 2022
cal
laboratory,B
ilhorod-
Dnistrovsky
State-
regulated

Orphanage, Teacher Dec Feb. Volunteer

Issue No: 3 Rev: 3 Issue Date: April 2022 Approved by: ……………………………… Page 2 of 6
© Bettal Quality Consultancy Cared 4 2011
In association with B&M CARE
 B&M CARE
Application for Employment Form C4-005
State 2021 2022 Contract
regulation expired
Bilhorod-
Dnistrovsky
Museum of Teacher of Chemistry Apr. Sep Moving to
interesting and biology ,Lab 2017 2017 another city
science Technician
Odesa

IMMUNOV Trainee-Microbiologist Oct Oct Contract

IROLOGIC 2016 2017 expired(it
AL was 1
LABORAT month)
ORY WITH
DIAGNOSI
S OF AIDS,
Odesa
Odesa Trainee Teacher 2016 Apr Contract
school 27 March 2016 expired(it
was 1
month)

Issue No: 3 Rev: 3 Issue Date: April 2022 Approved by: ……………………………… Page 3 of 6
© Bettal Quality Consultancy Cared 4 2011
In association with B&M CARE
 B&M CARE
Application for Employment Form C4-005
Further information
Please use this space to tell us about any other information that you feel will help your
application, including any other skills you may have. Please feel free to continue on a
separate sheet of paper if required.

Do you hold a current, clean driving licence? NO

Are you a Car Owner? NO
Do you have any holiday booked? YES
(If YES, please provide date Monday 24th- Fri 28th Oct.

National Insurance No SZ998650C

Covid vaccination status

Have you had both vaccinations YES

If yes please added dates

Vaccination 1 date 14/02/2022

Vaccination 2 date 10/03/2022

If no when are you planning on having the vaccinations

Declaration of right to work in the United Kingdom

Are you eligible to work in the UK? YES

Can you provide valid original documents? YES

Do you give your permission for your personal information to be shared with the Home Office
for the purposes of carrying out a work status check? YES

I declare that the information and documentation I have provided to B&M Care is genuine
evidence of my right to work in the United Kingdom.

Signed: ……………………………………………………… Date: 15/09/2022

Issue No: 3 Rev: 3 Issue Date: April 2022 Approved by: ……………………………… Page 4 of 6
© Bettal Quality Consultancy Cared 4 2011
In association with B&M CARE
 B&M CARE
Application for Employment Form C4-005
I give permission for my personal information to be shared with the Home Office for the purpose
of carrying out a work status check to provide evidence of my right to work in the United
Kingdom.

Signed: ……………………………………………………… Date: 15/09/2022

Declaration of Convictions / Disclosure of Information

Successful applicants will be asked to provide disclosure information as required under section
113 of the Police Act 1997. Disclosure information will not be used unfairly and a criminal
record will not necessarily be a bar to obtaining the position applied for. No offer of
employment will be withdrawn without discussion with the applicant. Note that false
declarations may be reported to the police.

Have you received any spent or unspent cautions and/or convictions? (please circle) NO

If yes please give details here

……………………………………………………………………………………………………
…………………………………………………………………………………………………….

DBS Privacy Policy

I have read the Standard/Enhanced Check Privacy Policy for applicants

https://www.gov.uk/government/publications/dbs-privacy-policies and I understand how DBS
will process my personal data and the options available to me for submitting an application.
A copy of this document is available from the Home manager if needed.

Signed: ……………………………………………………… Date: 15/09/2022

__________________________________________________________________________________________________________________

I certify that the information given in this application is true and accurate to the best of my
knowledge. I also understand that if I am appointed and information is subsequently found to be
false, I might be dismissed.

Signed: ……………………………………………………… Date: 15/09/2022

I certify that I wish references to be provided for future employers should I leave B&M Care.

Issue No: 3 Rev: 3 Issue Date: April 2022 Approved by: ……………………………… Page 5 of 6
© Bettal Quality Consultancy Cared 4 2011
In association with B&M CARE
 B&M CARE
Application for Employment Form C4-005

Signed: ……………………………………………………… Date: 15/09/2022

Data Protection Information

The information which you have supplied on this form will be processed and may be held on computer, and will be
held on your personal records file if you are appointed.
The information will also be used for equality monitoring and statistical purposes. By signing this application, you
will be deemed to have given your consent to this, including information which may be considered to be sensitive
and personal.

DBS Adult First Check & DBS Charge

The Criminal Records Bureau (CRB) and the Independent Safeguarding Authority (ISA) have
merged into the Disclosure and Barring Service (DBS). CRB checks are now called DBS checks

Please confirm the following by ticking the box:

Application for a DBS and DBS Adult First Check at the cost of £44.00, which I agree to
be deducted over three pay periods as follows - period 1: £14, period 2: £15, period 3:
£15.00.

Application for a DBS the cost of £38.00, which I agree to be deducted over three pay
periods as follows - period 1: £14, period 2: £14, period 3: £10.00.

I am a member of the DBS update Service.

Date15/09/2022 Signatue

Issue No: 3 Rev: 3 Issue Date: April 2022 Approved by: ……………………………… Page 6 of 6
© Bettal Quality Consultancy Cared 4 2011
In association with B&M CARE