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Title

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Last Name

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National Insurance No:

NMC Pin No: (Nurses Only)

Address

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Personal Details Personal Details

Nationality

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Employment Eligibility Employment Eligibility

Are you permitted to work in the United Kingdom? Are you permitted to work in the United Kingdom? Yes No

Can you provide evidence to prove eligibility? Can you provide evidence to prove eligibility? Yes No

What visa/permit/status do you currently hold?: What visa/permit/status do you currently hold?: Working Holiday Work Permit Leave to Remain I don't need a Visa Other

Please state what visa/permit you hold (If applicable):

Permit/Document No (If applicable):

Visa/Permit Expiry Date (If applicable):

Driving Details Driving Details

Do you have full Driving Licence that allows you to drive in the UK? Do you have full Driving Licence that allows you to drive in the UK? Yes No

If yes, please enter your Driving Licence No:

Languages Languages

English – Spoken English – Spoken Fluent Good Fair

English – Written English – Written Fluent Good Fair

Other Languages Spoken:

Next of kin details Next of kin details

First Name

Last Name

Relationship:

Email

NOK Phone Number

NOK Address

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NOK Postcode

Work History Work History

We need up to 10yrs work history please with no gaps. We need up to 10yrs work history please with no gaps.

Previous Job Title / Position Held

Date Previous Job Started

Date Previous Job Ended

Previous Job Description (Please list all other work history below, including start and end dates)

Education/Qualification History Education/Qualification History

Institution

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Year

Grade

Education (Please list all other education history below, including Courses, Years and Grades)

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References References

Ref Name 1

Relationship

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Ref 1 Phone Number

Ref 1 Address

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Ref 1 Postcode

Ref Name 2

Relationship

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Ref 2 Phone Number

Ref 2 Address

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Skills Experience & Training Skills Experience & Training

Please click on which training you have completed and the date on the notes (certificates must be provided). Please click on which training you have completed and the date on the notes (certificates must be provided). Manual Handling Basic life support Health and Safety Infection Control Other

Health Declaration Health Declaration

Do you or have ever suffered from long term illness?: Do you or have ever suffered from long term illness?: Yes No

Have you ever required sick leave for a back or neck injury?: Have you ever required sick leave for a back or neck injury?: Yes No

Do you suffer with any back or neck injuries? Do you suffer with any back or neck injuries? Yes No

Have you been in contact with anyone who is suffering from a contagious illness within the last six weeks? Have you been in contact with anyone who is suffering from a contagious illness within the last six weeks? Yes No

Do you suffer with a communicable disease?: Do you suffer with a communicable disease?: Yes No

If you have answered ‘yes’ to any of the above, please give details:

Are you currently receiving active medical attention? Are you currently receiving active medical attention? Yes No

Are you registered disabled?: Are you registered disabled?: Yes No

How many days have you been absent from work due to illness in the last 12 months?

State reason(s) for absence:

GP Details GP Details

GP Name:

GP Surgery Name:

GP Address

Town / City

GP’s Postcode

GP’s Phone Number

May we contact your Doctor for health check? May we contact your Doctor for health check? Yes No

Please Note Please Note

The above information will be held in strict confidence. If you are aware of any health issue that you feel may affect your ability to undertake responsibilities of the post, it is your responsibility to inform the Care Manager immediately. Again any details discussed in the meeting will be held in strict confidence.

DBS Declaration DBS Declaration

Do you have a current DBS (Disclosure Barring Service) certificate? Do you have a current DBS (Disclosure Barring Service) certificate? Yes No

Please enter disclosure number

Date of issue

Reference Number (if applicable):

DBS Check DBS Check I understand that a DBS check will be sort in the event of a successful application.

Terms of employment Terms of employment

If any provision of this Agreement should be held to be invalid it shall to that extent be severed and the remaining provisions shall continue to have full force and effect. You may be required to use personal vehicle to and from work. No fuel reimbursement will be given. You are responsible for meeting the cost of DBS Disclosure. The employer, in some circumstances, may agree to advance the cost only if you agree it to be deducted from your pay. Carers will achieve NVQ Level 2 within 2 years of the start of employment. All care staff and trainees, including all staff under 18, will register on and successfully complete Skills for care certified training programme. The Company has written and published a formal policy/procedure document covering employee grievances which relate to your employment. The document is entitled “Employee Discipline” and is available for review at any reasonable time. Please contact your Manager for further information, or to request to review a copy. If you are dissatisfied with any disciplinary or dismissal decision relating to you then you should, in the first instance, apply in writing, to the Care Manager stating the grounds for your appeal. The person who will consider the appeal may vary according to individual circumstances. The Company has written and published a formal policy/procedure document covering employee grievances which relate to your employment. The document is entitled “Employee Grievances” and is available for review at any reasonable time. Please contact your Care Manager for further information, or to request to review a copy. If a grievance cannot be resolved informally then you must put your grievance, in writing to your Care Manager. A simple form has been designed for this purpose. Employees with reading or language difficulties should seek assistance, for example, from a work colleague. Subsequent steps, including the right of appeal, are explained in the formal document. The following documents form part of this statement: Employee handbook Policy and procedure manual Notices

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Terms of employment Terms of employment I have read and agree to the terms

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