Electronic Application


Position Applied For
How did you hear about Assist Healthcare

Personal Details

Title
Surname
Previous Surnames
Forename(s)
Home Address
Town
County
Postcode
Home Tel.
Mobile Tel.
Work/Others Tel.
Email
Nationality
Country of Birth
Date of Birth
Are you Eligible to work in the U.K.?
Visa Number
National Insurance No.
Do you hold a UK driving license?
Are you eligible to drive in the U.K.?
Do you have the use of a car?
Passport Number

Next of Kin

Name
Relationship
Home Address
Postcode
Contact No(s)

Employment History

Please give a full and continuous employment history since leaving full time education explaining any gaps or breaks. Most Recent First.

Start DateFinish DatePosition Held & GradeEmployer Name and AddressReason for Leaving
Add Employment

References

Please supply the details of at least two referees of which, one must be your current or most recent employer. References will be sought upon receipt of this application.

Reference 1

Name
Address
Post Code
Telephone No.
Profession/Position
Relationship to applicant

Reference 2

Name
Address
Post Code
Telephone No.
Profession/Position
Relationship to applicant

Reference 3

Name
Address
Post Code
Telephone No.
Profession/Position
Relationship to applicant
If your application were successful, when would you be able to commence work?

NB. If applying for this position as a secondary income, responsibility is placed upon you the applicant to seek authorisation where necessary



Qualifications

Please be sure to include any qualifications relevant to the position for which you are applying.

NMC Pin NoPart of RegisterExpiry Date
Add Qualification

QualificationsDate obtainedPlace of Training
Add Qualification


Do you have any formal training in any of the below?

Training receivedDate obtainedTraining CompanyExpiry Date



Declaration of Health

Have you suffered any of the following

Yes/NoDetails
Back Trouble
Heart Disease / Blood Pressure
Epilepsy
Diabetes
Asthma / Chest Complaints
Dermatitis / Skin Problems
Any Major Operations
Do You Have Any Notifiable Diseases
Do You Smoke
Are You Taking Any Long Term Medication
Do You Suffer Any Allergic Reactions
Eye Sight Problems
Hearing Problems
Mental Health Problems
Infectious Diseases



Immunisations

Assist Healthcare strongly advises you to have up to date immunisations for at least the following. Immunisations are available from your local GP/ Health clinic who will advise you of current recommendations for adequate protection when working in healthcare environments. Please supply written confirmation of any immunisations you may have. Certain institutions may insist on proof of immunisation before allowing staff to work. It is YOUR responsibility to ensure that immunisations are kept up to date.

Yes/No
Rubella
Hepatitis B
Typhoid
Tuberculosis
Tetanus
Polio
Name & address of your General Practitioner

Declaration of Health



Rehabilitation of Offenders Act 1974

Assist Healthcare will use the DBS Disclosure service to assess applicants' suitability for positions of trust. It complies fully with the DBS Code of Practice and undertakes to treat all applicants for positions fairly. It undertakes not to discriminate unfairly against any subject of a Disclosure on the basis of conviction or other information revealed.

• Assist Healthcare is committed to the fair treatment of its staff, potential staff or users of its services, regardless of race, gender, religion, sexual orientation, responsibilities for dependants, age, physical/mental disability or offending background.

• Assist Healthcare promotes equality of opportunity for all with the right mix of talent, skills, and potential and welcomes applications from a wide range of candidates, including those with criminal records. Candidates are selected for interview based on their skills, qualifications and experience.

• A Disclosure is requested thorough risk assessment indication that one is both proportionate and relevant to the position concerned, this is due to the types of environments our company works within. For those positions where a Disclosure is required, all application forms, job adverts and further details will contain a statement that a Disclosure will be requested in the event of the individual being offered the position.

• Where a Disclosure is to form part of the recruitment process, Assist Healthcare encourages all applicants called for interview to provide details of their criminal record at an early stage in the application process. This information is sent under separate, confidential cover, to a designated person within the Company, which guarantees that this information is only seen by those who need to see it as part of the recruitment process.

• As the nature of the position involves working with vulnerable adults this allows Assist Healthcare to ask questions about the entire criminal record rather than only asking about 'unspent' convictions as defined in the Rehabilitation of Offenders Act 1974. By virtue of the rehabilitation of offenders act 1974 (Exceptions) order 1975, the provisions of section 4.2 of the rehabilitation of offenders act 1974 do not apply to any employment which is concerned with the provisions of health services and which is of such a kind as to enable the holder to have access to persons in receipt of such services in the course of his normal duties. Assist Healthcare ensures that all staff who are involved in the recruitment process have been suitably trained to identify and assess the relevance and circumstances of offences. It will also ensure that they have received appropriate guidance and training in the relevant legislation relating to the employment of ex-offenders, e.g. the Rehabilitation of Offenders Act 1974. At interview, Assist Healthcare aims to ensure that an open and measured discussion takes place on the subject of any offences or other matter that might be relevant to the position sought and could lead to withdrawal of an offer of employment.

• Assist Healthcare will make every subject of a DBS Disclosure aware of the existence of the DBS Code of Practice and make a copy available on request.

• Assist Healthcare undertakes to discuss any matter revealed in a Disclosure with the person seeking the position. Any person seeking employment who have a positive disclosure will be asked for a written explanation before withdrawing a conditional offer of Employment.

Have you ever been convicted of a criminal offence?
(If yes please give details including dates)

Declaration

I declare that I have answered the above questions honestly and fully and that I am not aware of any physical or mental disability, which may affect my working capacity. I realise that any false or incomplete statement on my part will render me liable to disciplinary action or dismissal. I also understand that my details will be submitted for a check by the criminal records bureau.

I agree to comply with the current health & safety at work act.

It is a condition of employment that you work flexibly in accordance with the requirements of the company. Accordingly if accepted and employed you acknowledge that there may be periods when no work is available and the company has no obligation to provide an employee with any work or to provide any minimum number of hours in any day or week.

I hereby give permission for Assist Healthcare to contact the UK Border Agency to seek verification of my documents.

I also confirm that I give permission for my documentation to be viewed as appropriate by official bodies for the purposes of internal and external audits.

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Personal Statement

Please Use the box to the right to add any additional comments or attach your CV.
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