Application Form - The Ultimate in Care.

What position are you interested in ? *

Enter your NMC PIN (RGN, RMA & RNA only)

Personal Details

Enter your details as they appear on your documents.

Surname

Middle Names

Forename

Date of Birth

Mobile Number

Home Phone

Your Email

Confirm Your Email

House Name or Number

First line of address

Town/City

Post Code

County

Do you have National Insurance Number?

Enter it here otherwise leave blank

Nationality

Ethnicity

Religion

Do you hold a valid UK driving licence?

Level of spoken English

Are you available to start work immediately?

Next of Kin

Realtionship to you

Their Mobile Number

Their Email

References

References are normally requested for candidates selected for interview. Please provide the name and email address of at least one work-related referee. This should normally be your current employer or, if you are currently unemployed or self-employed, your most recent employer.

1st referee Surname

1st referee Forename

1st referee Email

2nd referee Surname

2nd referee Forename

2nd referee Email

DBS

Any applicant who cannot provide a valid DBS certificate or a full immunisation record will be required to obtain these at their own expense. The company will cover the cost of mandatory training updates. However, cancellations made less than 48 hours before training, or failure to attend, may result in the cost being charged to the candidate.

Do you currently hold a valid Enhanced DBS certificate?

Uniforms

Candidates may be required to purchase uniforms at a cost of £30. This amount will be deducted from your timesheet after you commence employment. Please indicate your required uniform size and quantity by completing the section below.

Size

Quantity

Health Declaration

Applicants applying for roles that involve Exposure Prone Procedures (EPPs) must provide satisfactory evidence of immunity to, or freedom from, Hepatitis B infection. Evidence must be provided in the form of a laboratory blood test result or a letter from your GP, Occupational Health Service, or previous Occupational Health provider confirming immunity or freedom from infection.

Do you consider yourself to have a disability under the Equality Act 2010?

Do you have any long-term illnesses or medical conditions?

Do you suffer from any neck or back pain or injuries?

Do you have any communicable or infectious diseases?

If you answered "Yes" to any of the above, please provide details below.

Please indicate whether you have ever had any of the conditions listed below.

Healthcare workers who are infected with HIV must remain under regular medical and occupational health supervision (Reference: Department of Health, 1994).

Tetanus Hepatitis B & or C Tuberculosis Human Immunodeficiency Virus (HIV)

If you have selected any of the above checkboxes, please provide details below.

Are your Covid-19 vaccinations up to date?

GP Details

I understand that my GP may be contacted regarding my health.

The information provided above will be treated in the strictest confidence. If you have any health condition or concern that may affect your ability to carry out the duties and responsibilities of the role, it is your responsibility to inform the Compliance Manager immediately. Any information disclosed to the Compliance Manager will be treated as confidential and handled in accordance with applicable data protection requirements.

May we contact your GP?

GP''s Name

GP's Practice

Address

Town

Post Code

Phone Number

Their Email

Declaration

1. I declare that, to the best of my knowledge, the information provided in this application form, together with any accompanying documents submitted, is true, accurate, and complete. I understand that any false, misleading, or omitted information may result in the withdrawal of any offer of employment or, if employed, disciplinary action up to and including dismissal.

2. I consent to a medical assessment and interview if deemed necessary as part of the recruitment process.

Consent

Date

Documents submission