Wellness Application form
Wellness Application Form Please ensure that you complete the application form in full as we cannot accept incomplete applications.
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Personal Details Title – Select – Mr Mrs Miss Ms First Name Last Name DOB Do you prefer a Phone call or an email? Phone call EmailEmail Phone/Mobile Address Address Line 1 City Zip Code Country Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belau Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo (Kinshasa) Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of the Congo (Brazzaville) Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (Dutch part) Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) United States (US) Minor Outlying Islands United States (US) Virgin Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Save & Resume
Previous Next I understand this role may include: Shift work, Unsociable Hours, Lone working involved. Yes NoPlease Select preferred days. Thursday Tuesday Sunday Monday Friday Wednesday Saturday Do you have a valid driver’s Licence? Yes NoDo you own a Car? Yes NoAny Endorsements Yes NoPlease briefly tell us what happened. Are you a United Kingdom (UK) National? Yes NoUpload your ID (s). Choose File If NO, please provide details of your current immigration status here. Are you related to any member of staff or Service Users? Yes NoIf YES, please detail your relationship
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: www.gov.uk/definition-of-disability-under-equality-act- 2010.
For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process? Yes NoIf YES, please explain Save & Resume
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Education History All qualifications will be subject to a satisfactory check.
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Do you have any supporting documents? Yes NoUpload any supporting documents Choose File
Training Courses Attended or completed online (evidence of attending or attended courses is required).
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Employment History Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained.
Your employment History
Upload any supporting documents Choose File Use this section to detail any gaps in employment and why Save & Resume
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References: Please provide names, addresses and telephone numbers for referees below whom we may approach for a reference. 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. Referee One Referee Two
Referees Referee
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Safeguarding / 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 confidence. The Rehabilitation of Offenders Act 1974 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. Crossover Care Limited 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 NoDo you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country? Yes No I consented to have this website store my information so they can respond to my inquirySave & Resume
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