For Referees Only

Reference Request Form

Revive Rise Complex Home Care · Nurse-Led Professional Care Services

Confidential

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Revive Rise

Affordable, ethical care led by experienced nurses — tailored to your needs with full CQC compliance and dignity at its core.

Personal Info

Employment

Qualifications

References

Declaration

Position Applied For

Tell us which role you're applying for and your preferred location

Position Applied For *

Preferred Location *

Personal Details

Your name, address, contact and professional registration

Title *

First Name *

Last Name *

Address

Address Line 1 *

Address Line 2

Town / City *

Postcode *

Phone Number *

Email Address *

Date of Birth *Required for right-to-work checks and DBS compliance.

National Insurance Number *

NMC Registration

Do you hold a current NMC PIN? *

Yes No

NMC PIN Number * Your 8-character NMC Personal Identification Number.

Eligibility & Equality

Right to work and equal opportunities — all fields required

Do you have the right to work in the UK? *

Yes No

Gender *

Male Female Non-binary Prefer not to say

Ethnicity *

White Mixed / Multiple Asian / Asian British Black / Caribbean Other Prefer not to say

Do you consider yourself to have a disability? *

Yes No Prefer not to say

Criminal Convictions

Do you have any unspent criminal convictions? *

Yes No

Are you currently facing any criminal charges? *

Yes No

Have you ever been disqualified from working with children or vulnerable adults? *

Yes No

If yes to any of the above, please provide details

Employment & Education History

Minimum 5 years of experience required — most recent first.

Please provide at least 2 employment / education entries. Use "Add Another" if you have more than 2.

Most Recent Employer / Institution Required

Employer / Institution Name *

Job Title / Course *

From *

To *

Reason for Leaving *

Employer / Institution 2 Required

Employer / Institution Name *

Job Title / Course *

From *

To *

Reason for Leaving *

Please explain any gaps in your employment or education history *All gaps must be explained. This is a mandatory safeguarding requirement.

Qualifications & Training

Education, professional qualifications and care training courses

Qualifications (minimum 3 required)

Please provide at least 3 qualifications. Use "Add Another" if you have more than 3.

Qualification 1 Required

Qualification *

Date Achieved *

Institution *

Qualification 2 Required

Qualification *

Date Achieved *

Institution *

Qualification 3 Required

Qualification *

Date Achieved *

Institution *

Care Training Courses

Training Course 1 Optional

Course Name

Date Completed

Do you hold a full UK driving licence? *

Yes No

Do you have access to a vehicle? *

Yes No

Skills & Experience

Tell us about yourself and why you'd be great for this role

Relevant Care Experience *

Key Skills *

How do you handle challenging situations? *

Next of Kin Details

Emergency contact information — mandatory

Primary Next of Kin Required

Full Name *

Relationship to You *

Contact Number *

Alternative Contact Number

Address *

References

Two references required — both from most recent employer or educational institution

Both references must be from your most recent employer or educational institution — one must be your line manager or supervisor. Please obtain their permission before submitting.

Reference 1 Required

Full Name *

Job Title *

Relationship to You *

Organisation *

Contact Number *

Email Address *

Reference 2 Required

Full Name *

Job Title *

Relationship to You *

Organisation *

Contact Number *

Email Address *

I confirm that I have obtained permission from both referees and consent to Revive Rise contacting them. *

Bank Details

Required for payroll — stored securely and used only for salary payments

Your bank details are encrypted and processed securely in accordance with GDPR 2018. They will only be used for salary payment purposes.

Bank Name *

Account Holder Name *

Sort Code *

– –

6-digit sort code in XX–XX–XX format

Account Number * 8 digits — no spaces or dashes

Emergency Contact Information

Person to contact in the event of a workplace emergency — mandatory

Primary Contact Required

Full Name *

Relationship to Employee *

Phone Number (Home) *

Phone Number (Mobile) *

Address *

Secondary Contact Optional

Full Name

Relationship to Employee

Phone Number (Home)

Phone Number (Mobile)

Address

Declaration & Consent

DBS check consent and application declaration

DBS Check Consent *

This role requires an enhanced DBS check. Do you consent to this?

Yes, I consent No

By submitting this application, you confirm that the information provided is true and accurate. You understand that providing false information may result in the withdrawal of any job offer or dismissal. You consent to Revive Rise processing your personal data in accordance with GDPR 2018 for recruitment purposes.

I confirm the above declaration is accurate and I agree to the GDPR consent statement. *

Additional Information

Anything else you'd like us to know

Additional Information Optional

Your data is protected and handled in accordance with GDPR 2018

Why Join Revive Rise?

Flexible Hours

Full-time, part-time and bank shifts available

Full Training Provided

Comprehensive induction and ongoing CPD

Nurse-Led Team

Work alongside experienced registered nurses

CQC Registered

Regulated, safe and fully compliant care

Meaningful work caring for complex needs clients

Need Help Applying?

Our team is happy to help you with your application. Contact us directly.

PHONE

024 7692 0269

EMAIL

paul@reviverise.co.uk

+44 7508 031542

Our Office

Our team is happy to help you with your application. Contact us directly.

Mercury Business Centre 3 Mercury Park Tamworth, B77 4RP

Position Applied For

Tell us which role you're applying for and your preferred location

Position Applied For *

Preferred Location *

Personal Details

Your name, address and contact information

Title *

First Name *

Last Name *

Address

Address Line 1 *

Address Line 2

Town / City *

Postcode *

Phone Number *

Email Address *

Date of Birth *

National Insurance Number *

Required for right-to-work checks and DBS compliance.

Eligibility & Equality

Right to work and equal opportunities information

Do you have the right to work in the UK? *

Yes Noe

Gender *

Male Female Non-binary Prefer not to say

Ethnicity

White Mixed / Multiple Asian / Asian British Black / Caribbean Other Prefer not to say

Do you consider yourself to have a disability?

Yes No Prefer not to say

Criminal Convictions

Do you have any unspent criminal convictions?

Yes Noe

Are you currently facing any criminal charges?

Yes Noe

Have you ever been disqualified from working with children or vulnerable adults?

Yes Noe

If yes to any of the above, please provide details

Employment History

List your most recent employers first (up to 4)

Most Recent Employer Required

Employer Name *

Job Title *

From *

To *

Reason for Leaving *

Previous Employer 2 Optional

Employer Name

Job Title

From

Reason for Leaving

Previous Employer 3 Optional

Employer Name

Job Title

From

Reason for Leaving

Previous Employer 4 Optional

Employer Name

Job Title

From

Reason for Leaving

Please explain any gaps in your employment history

Qualifications & Training

Education, professional qualifications and care training courses

Criminal Convictions

Qualification 1 Required

Qualification *

Date Achieved *

Institution *

Qualification 2 Optional

Qualification

Date Achieved

Institution

Qualification 3 Optional

Qualification

Date Achieved

Institution

Qualification 3 Optional

Qualification

Date Achieved

Institution

Care Training Courses

Care Training Courses 1 Optional

Course Name

Date Completed

Care Training Courses 2 Optional

Course Name

Date Completed

Care Training Courses 3 Optional

Course Name

Date Completed

Care Training Courses 4 Optional

Course Name

Date Completed

Do you hold a full UK driving licence?

Yes No

Do you have access to a vehicle?

Yes No

Skills & Experience

Tell us about yourself and why you'd be great for this role

Key Skills

Relevant Care Experience

How do you handle challenging situations?

References

At least one must be your most recent line manager or supervisor

Please provide two referees who can vouch for your suitability. One must be your most recent manager/supervisor. Please obtain their permission before submitting.

Reference 1 Required

Full Name *

Relationship to You *

Contact Number *

Email Address

Reference 2 Optional

Full Name

Relationship to you

Phone Number

Email Address

Declaration & Consent

DBS check consent and application declaration

This role requires an enhanced DBS check. Do you consent to this?.

DBS Check Consent *

Yes, I consent No

By submitting this application, you confirm that the information provided is true and accurate to the best of your knowledge. You understand that providing false information may result in the withdrawal of any job offer or disciplinary action, including dismissal. You consent to Revive Rise processing your personal data in accordance with GDPR 2018 for the purposes of recruitment and employment.

I confirm that the above declaration is accurate and I agree to the GDPR consent statement *

Additional Information

Anything else you'd like us to know

Additional Information (optional)

Application Form

Position Applied For:

Location:

Section 1: Personal Details

1. Full Name:

Title (Mr/Mrs/Miss/Ms/Other):

First Name:

Last Name:

2. Address:

Address Line 1:

Address Line 2:

Town/City:

Postcode:

3. Contact Details:

Phone Number:

Email Address:

4. Date of Birth:

(Required for right-to-work checks and DBS compliance.)

5. National Insurance Number:

(Required for payroll and tax purposes.)

6. Do you have the right to work in the UK?

YesNo

(Proof of right to work will be required, e.g., passport, visa, or other documentation.)

Section 2 : Equality and Diversity Monitoring

Revive Rise is committed to promoting equality and diversity. This information is for monitoring purposes only and will not affect your application.

1. Gender:

MaleFemaleNon-binaryPrefer not to say

2. Ethnicity:

WhiteMixed/Multiple Ethnic GroupsAsian/Asian BritishBlack/African/Caribbean/Black BritishOther Ethnic GroupPrefer not to say

3. Do you consider yourself to have a disability?

YesNoPrefer not to say

(Revive Rise is a Disability Confident employer and will make reasonable adjustments to support your application.)

4. Do you have any criminal convictions, cautions or reprimands, bind-overs or have you been given a warning for a criminal offence?

YesNo

5. Do you currently have criminal charges pending or are you under a criminal investigation?

YesNo

6. Have you ever been disqualified from working with children or vulnerable adults, or are sanctions imposed on you by a regulatory body?

YesNo

If your answer to any of the above questions is ‘Yes’, please provide details below.

If you are providing additional details, please mark your application as “PRIVATE AND CONFIDENTIAL FOR THE ATTENTION OF THE HR MANAGER” (either on the envelope or in the subject of the email).

Section 3: Employment History

1. Current/Most Recent Employer:

Employer Name:

Job Title:

Dates of Employment: From To

Reason for Leaving:

2. Previous Employment:

Employer Name:

Job Title:

Dates of Employment: From To

Reason for Leaving:

3. Previous Employment:

Employer Name:

Job Title:

Dates of Employment: From To

Reason for Leaving:

4. Previous Employment:

Employer Name:

Job Title:

Dates of Employment: From To

Reason for Leaving:

5. Gaps in Employment:

Please explain any gaps in your employment history.

Section 4: Qualifications and Training

1. Relevant Qualifications:

Qualification:

Institution:

Date Achieved:

2. Relevant Qualifications:

Qualification:

Institution:

Date Achieved:

3. Relevant Qualifications:

Qualification:

Institution:

Date Achieved:

4. Relevant Qualifications:

Qualification:

Institution:

Date Achieved:

5. Care-Related Training:

Training Course:

Date Completed:

6. Care-Related Training:

Training Course:

Date Completed:

7. Care-Related Training:

Training Course:

Date Completed:

8. Care-Related Training:

Training Course:

Date Completed:

9. Do you hold a valid driving license?

YesNo

10. Do you have access to a vehicle?

YesNo

Section 5: Skills and Experience

1. Please describe your experience in domiciliary care or a similar role:

2. What skills do you possess that make you suitable for this role?

3. How would you handle challenging situations with clients?

Section 6: References

Please provide two people who we may contact for a reference on your suitability for the role. One must be your most recent line manager or supervisor, and the second should also be a previous manager/supervisor. Please ask your referees for permission to give their details before submitting your application.

1. Reference 1:

Name:

Relationship to You:

Contact Number:

Email Address:

2. Reference 2:

Name:

Relationship to You:

Contact Number:

Email Address:

Section 7: Declaration

1. Disclosure and Barring Service (DBS) Check:

(This role requires an enhanced DBS check. Do you consent to this?)

YesNo

2. Declaration:*

I confirm that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in the withdrawal of any job offer or disciplinary action, including dismissal. I consent to Revive Rise processing my personal data in accordance with GDPR 2018 for the purposes of recruitment and employment.

Section 8: Additional Information

1. Is there anything else you would like to tell us about your application?

Reference Request Form

Join Our Team – Apply for Jobs at
Revive Rise

Personal Info

Employment

Qualifications

References

Declaration

Why Join Revive Rise?

Flexible Hours

Full Training Provided

Nurse-Led Team

CQC Registered

Regulated, safe and fully compliant care

Need Help Applying?

PHONE

EMAIL

WhatsApp

Our Office

Application Form

Section 1: Personal Details

Section 2 : Equality and Diversity Monitoring

Section 3: Employment History

Section 4: Qualifications and Training

Section 5: Skills and Experience

Section 6: References

Section 7: Declaration

Section 8: Additional Information

Quick Links

Services

Information

Phone

Email

Location

Reference Request Form

Join Our Team – Apply for Jobs at Revive Rise

Personal Info

Employment

Qualifications

References

Declaration

Why Join Revive Rise?

Flexible Hours

Full Training Provided

Nurse-Led Team

CQC Registered

Regulated, safe and fully compliant care

Need Help Applying?

PHONE

EMAIL

WhatsApp

Our Office

Application Form

Section 1: Personal Details

Section 2 : Equality and Diversity Monitoring

Section 3: Employment History

Section 4: Qualifications and Training

Section 5: Skills and Experience

Section 6: References

Section 7: Declaration

Section 8: Additional Information

Phone

Email

Location

Join Our Team – Apply for Jobs at
Revive Rise