Application Form

Have you ever been dismissed from a professional or nursing post? Yes No If 'yes' please give details below: Date of Conviction: Nature of Conviction: 12. Details of any convictions... continued. Are you currently suspended, on notice of dismissal from your employment or under investigation from any employer? Yes No If ...
650KB Sizes 1 Downloads 261 Views
Application Form A-Best Nursing & Care 65 Wellington Rd South,

Please complete all sections of the application form and return to the address below. Please continue on separate sheets of paper, if necessary. The information provided on this form will be used as part of the selection process.

Stockport SK1 3RU Tel: 0161 222 9445 Email: [email protected] www.abestcare.co.uk

Please affix a standard Passport sized photo’s below

1. Personal Details Please complete this section using your full NMC registered name. Title: Mr

Mrs

Ms

Miss

First Name: Surname: Sex: Male

Female

Other

Date of Birth: Marital Status: Other Names: NMC Pin No:

2. Contact Details

3. Next of Kin Contact Details

Current Address:

Contact Name: Relationship: Address:

Postcode: Work Telephone: Home Telephone: Mobile:

Postcode:

Email Address

1st Contact No: 2nd Contact No: Email Address:

A-Best Nursing & Care

1

1/7

4 a). Education

istory

ease i e detai s o your education history. continue on a se arate iece o

Name of School / College / University

ualification / Course

Date From:

Date To:

a er i necessary)

Additional Details:

Name of School / College / University

ualification / Course

Date From:

Date To:

Additional Details:

Name of School / College / University

ualification / Course

Date From:

Date To:

Additional Details:

Name of School / College / University

ualification / Course

Date From:

Date To:

Additional Details:

A-Best Nursing & Care

2/7

4 b). mployement History ease i e detai o your e oye ent o er the ast years. a s o er onths ust e accounted or. nc ude the onth and the year startin ith your current or ast o continue on a se arate iece o a er i necessary).

o

.

ob Title:

mployer s Name: Date To:

Date From: Reason for Leaving:

. ob Title:

mployer s Name: Date To:

Date From: Reason for Leaving:

. mployer s Name:

ob Title:

Date To:

Date From: Reason for Leaving:

4.

mployer s Name:

ob Title:

Date To:

Date From: Reason for Leaving:

A-Best Nursing & Care

3/7

5. Immigration Status British/EC Nation: Yes

9. Bank Details... Continued

No

Marital Status:

Passport No:

Other Names:

Expiry Date:

IBAN:

Issued at:

Swift/BIC:

Type of visa held (if any):

Branch Address:

Expiry Date:

6. Professional Society / Union

Postcode:

Name of Society/Union:

10. References (please provide two

Type of Membership:

references)

Renewal Date: Reference 1:

Membership PIN No: Are you currently under investigation by the NMC or any other organisation? Yes

No

Name: NMC Pin (if applicable): Address:

7. Tax Status 1. PAYE:

Yes

No

Postcode:

P45 enclosed:

Yes

No

Mobile:

P46 enclosed:

Yes

No

Fax:

2. LTD company: Yes

No

Email:

VAT Registered : Yes

No Reference 2:

Please provide certificate of incorporation, Ltd co bank statement, and VAT certifificate.

Name: NMC Pin (if applicable): Address:

8. Bank Details Bank Name: Account Name:

Postcode:

Account No:

Mobile:

Sort Code:

Fax:

Reference (if applicable):

Email:

Please Continue...

A-Best Nursing & Care

Both references must be from within the past twelve months and Your referees must be a senior grade to yourself and you must have worked for the person for a period of more than three months. 4/6

11. Declaration of Criminal Record

12. Details of any convictions... continued

Rehabilitation of Offenders Act 1974 (exceptions) Order 1975

Are you currently suspended, on notice of dismissal from your employment or under investigation from any employer?

Due to the nature of the work for which you are applying, the provision of section 4 (2) of the Rehabilitation of Offenders Act 1974 does not apply by virtue of the Rehabilitation of Offends Act 1974 (exceptions) Order 1975. Applicants therefore NOT entitles to withhold information about convictions which for purposes are ‘spent’ under the provisions of the Act. In the event of employment, any failure to disclose such convictions will result in your removal from our register. Any information you may give will, of course, remain strictly confidential. A-Best Nursing & Care may contact you for your permission to disclose such details if relevant to the position you are applying for. Have you even been police checked?: Yes

No

Date you were last police checked: Please provide evidence of your most recent Police clearance from your country of origin. (If within last 6 months)

Yes

No

If ‘yes’ please give details below

Any further information required, please refer to additional notes section.

13. Your general Practitioner’s details Name: Address:

Please provide your ISA registration Number, if applicable:

Please provide your Scottish Vetting & Barring Scheme Number, if applicable:

Postcode: Telephone

14. Training Declaration 12. Details of any convictions Have you ever been convicted of a criminal offence: Yes

No

If ‘yes’ please give details below:

Date of Conviction: Nature of Conviction: Have you ever been dismissed from a professional or nursing post? Yes

No

If ‘yes’ please give details below:

I understand that it is my responsibility to undergo an annual appraisal and attend mandatory training in the following disciplines: Manual Handling patients, Moving and Handling, Health and Safety, Fire procedures; fire safety; infection control; COSHH; RIDDOR; Risk incident Reporting; Complaints Handling/Major Incident/Alerts; Lone Worker Training; Bleep Systems – Fast Call/Cardiac Arrest/Fire; On Site Security; Information Security; Crash Call Procedures; Hot spot Mechanisms; Handling of Violence and Aggression; Cross Infection; Aseptic Non Touch Technique; Computer Use; Notififiable Diseases; Clinical Governance; Data Protection Act 1988; Ionising Radiation; Risk Incident Reporting; The Caldicott Principle; Working Time Directive. This list is not an exhaustive one, however it reflects the type of training and development needed to undertake your future roles and responsibilities. Print Name:

Date of Conviction: Nature of Conviction:

A-Best Nursing & Care

Date: Signature

5/7

15. Working Times Regulations The Working Time regulations 1998 (“the regulations”) require A-Best Nursing & Care (“The Company”) to limit your average weekly working time to 48 hours unless you agree with the company that the limit shall not apply to you. The company wished to have an agreement with you. It proposes an agreement (which will apply until terminated by notice) on the basis that: 1. The 48-hour limit on average weekly time will not apply to you. 2. You may terminate the agreement (so that the 48-hour time limit would apply to you) by giving the person at the company to whom you usually report 4 weeks’ written notice. Under the regulations, the company must keep records relating to your working time. This is the case whether or not you reach an agreement with the company about waiving working time limits.

17. Mandatory Induction, Information &Training Declaration I the undersigned hereby declare that I have read and understood the A-Best Nursing & Care Induction handbook and that I am already trained in the NHS standards in all the areas as specified in the handbook. In the event that I require further training in any area I will inform A-Best Nursing & Care without delay. I will ensure my annual mandatory training is updated and will forward copies of my certification to A-Best Nursing & Care. I believe the above to be a true declaration and I fully understand that should it come to light following my employment with the prospective employer, that any of the information I have provided within this application proved to be false or a misrepresentation my employer may terminate my employment with immediate effect. Print Name: Date:

If you accept the Company’s proposals, please sign below. This document will then be the record of agreement

Signature

Print Name: Date: Signature

18. Declaration

16. Access to Medical Records I the undersigned hereby give permission to A-Best Nursing & Care, to have access to my medical records pertinent to my immunisation and blood test history Print Name: Date:

I the undersigned hereby declare that the information I have given in this application form is true to the best of my knowledge and belief. I agree that if I have given any false or misleading information, or do not give relevant information now or in the future, this may result in the termination of an assignment without notice. I acknowledge that I have been given a copy of the terms and conditions and access to the nurse induction handbook by ABest Nursing & Care and will abide by those terms and conditions. Furthermore I hereby consent to A-Best Nursing & Care disclosing to the authority, or any person, firm or organisation duly authorised on the authority’s behalf or NHS national framework, documentationfor the proposed of an external audit required in accordance with the NHS national framework.

Signature Print Name: Date: Signature

A-Best Nursing & Care

6/7

19. Document Checklist Please bring the following items and the completed list with you to the interview, using the tick boxes to check off items.

Passport/Proof of Identity A Complete Support / Health Care Worker application form. Curriculum Vitae Copies of both parts of your driving licence, insurance certificate, tax and M.O.T(Support Worker) Proof of National Insurance Number 2 Passport Photographs, recent and matching, signed and dated on the back 2 Forms of ID and Proof of Address. Original Certificate of any course or qualification you have completed during your professional career. CRB(DBS) Payment: Please note that, it is mandatory to have a CRB check for each agency that you join

Original Training Certificate completed within the past year: Manual Handling

First Aid

Infection Control

Basic Food Hygiene

Safeguarding Vulnerable Adults(POCA and POVA)

Fire Safety

Health and Safety

Medication Training

A-Best Nursing & Care

7/7