EASTLEIGH COMMUNITY SERVICES 
HELP IN THE HOME SERVICE

APPLICATION FOR REGISTRATION

 

PERSONAL DETAILS

SURNAME:

FORENAMES:

TITLE:

DATE OF BIRTH:

ADDRESS:

POST CODE:

TELEPHONE NUMBER:

AGE:

 

EXPERIENCE AND QUALIFICATIONS

Please give details of any relevant experience/qualifications:

 

 

AVAILABILITY (please tick)

MON

TUES

WED

THUR

FRI

AM (9-1)

PM (1-4)

 

REFERENCES: Please give the names of two referees (not relatives) one of whom should be your present or last employer (if not, a priest, a doctor or another professional person)

NAME:

NAME:

ADDRESS:

ADDRESS:

TOWN:

 TOWN

POSTCODE:

POSTCODE:

TELEPHONE NUMBER:

TELEPHONE NUMBER:

IN WHAT CAPACITY IS THE PERSON KNOWN TO YOU?

IN WHAT CAPACITY IS THE PERSON KNOWN TO YOU?

MISCELLANEOUS

DO YOU HAVE ACCESS TO TRANSPORT? YES/NO

PLEASE INDICATE WHAT SORT OF TRANSPORT? _____________

HOW MANY HOURS WOULD YOU LIKE TO WORK PER WEEK? ______________

“I certify that the information I have given on this form is accurate to the best of my knowledge”

SIGNED:                                                                           DATE:

 

Please return to: 

Service Co-ordinator
Help in the Home Service, Eastleigh Community Services

ECS House, 16 Romsey RoadEastleigh, S050 9AL
 
Telephone: 023 8090 2400