Candidate Application Form

First Name

Last Name

Date of Birth (DD/MM/YYYY)

Title

Address

Address Line 1

Address Line 2

Town/City

County

Postcode

Country

Landline (optional)

Mobile

National Insurance Number

Next of Kin

First Name

Last Name

Relationship to you (e.g. Sister)

Their Contact Number

Work Requirements

What position are you applying for?

When are you able to start work? (DD/MM/YYYY)

When are you available until?

Professional Body Registration

Full/Provisional (Please select one)

Yes

Specialist Register: (Please select one)

Yes

Professional Body Membership (please provide details of any membership to professional bodies such as Royal Colleges):

Annual Appraisal

Most recent appraisal date:

Appraisal location:

Name of Appraiser:

Position of Appraiser:

Name of Appraiser:

Position of Appraiser:

Next Appraisal due:

Appraisal booked? (choose one)

Yes

Current and Previous Employment

Please list your last 10 years of employment, starting with your current or most recent employer. It is important that you explain any gaps in employment of over 3 months in duration. If necessary, please continue on a separate sheet.

Name and address of Hospital/Employer Please write, Position, From Month/Year and To Month/Year

Professional Indemnity Insurance

AHC ltd strongly advises you to have your own Professional Indemnity Insurance. If you do not, MedicsPro strongly advises that you contact a suitable organization to arrange the relevant cover.

Do you already have Professional Indemnity Insurance in place?*

Yes *

* If Yes, and not included in the above, please state when and in what capacity:

Have you ever worked for AHC Ltd previously?

Yes

Professional Qualifications and Training

(include Post Graduate Diploma, training courses etc)

Qualification, Place obtained From (month/year) To (month/year)

Date of last Basic Life Support Training (DD/MM/YYYY)

Date of last Health and Safety Training (DD/MM/YYYY)

Date of last Moving and Handling Training (DD/MM/YYYY)

Please provide documentary evidence of all of the above; all certificates will be verified

Professional Referees

Please give the names and contact details of 3 professional referees from your current/previous employment. Referees must have worked in a senior position to yourself. Please be aware that Allhands Care are unable to offer you work until satisfactory references have been obtained, and the Allhands Care are required to obtain references for you on an annual basis.

Reference 1

Organisation:

Reference Name:

Professional Work Address

Telephone:

Can we contact immediately?

Yes

Dates employed (DD/MM/YYYY)

Professional Title:

Capacity in which known

Reference 2

Organisation:

Reference Name:

Professional Work Address

Telephone:

Can we contact immediately?

Yes

Dates employed (DD/MM/YYYY)

Professional Title:

Capacity in which known

Reference 3

Organisation:

Reference Name:

Professional Work Address

Telephone:

Can we contact immediately?

Yes

Dates employed (DD/MM/YYYY)

Professional Title:

Capacity in which known

Declaration

Criminal Records

CRB/DBS no. & Issue Date

CRB/DBS No

Issue Date

The work you have applied for is exempt from the Rehab of Offenders Act 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need to be disclosed. You are not entitled to withhold information about convictions, which for other purposes may be considered spent. Only relevant convictions and other information will be taken into account so disclosure need not necessarily be a bar to obtaining work with Allhands Care. I consent to Allhands Care checking my status through the update service Please tick:

Have you ever been convicted by the courts of cautioned, reprimanded or given a warning by the police?

Yes

Are you aware of any Police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this post?

Yes

Have you ever had a Police check in another country? If so, please provide details and enclose a copy if held.

Yes

*If you have answered YES to any of the above, please give details:

Please note that if at any stage whilst working for AHC we receive a DBS Enhanced Disclosure that highlights information you have not declared, then you will be removed from your assignment.

Declarations

Have you ever been subject to disciplinary action or are currently being investigated due to alleged misconduct?

Yes

I understand that if I am charged or cautioned after signing this declaration, I must inform AHC. I acknowledge that I have been given a copy of the Terms and Conditions of Service issued by MedicsPro, which is mine to keep, and furthermore that I have read those Terms and Conditions and agree to abide by them. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my Occupational Health Questionnaire.

I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future, which MedicsPro may cease to offer me further agency placements without notice, as well as a claim for recovery of any payments I have received, together with a claim for loss of profit to I acknowledge and confirm that AHC is authorised to apply for and obtain a Criminal Records Check and references from any previous employers and educational establishments. I acknowledge that my personal details will be stored and handled correctly by AHC in accordance with the Data Protection Act 1998 however; I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents – CRB, Occupational Health, References) I understand that if I am on a student visa I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student changes, I must inform.

I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform MedicsPro. I hereby give consent for MedicsPro to check my Visa status via the Bio-Metric residence permit checking service. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for I must inform MedicsPro immediately. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body (e.g. GMC / NMC / HPC / RPSGB) or being investigated by my current or previous employer. I will inform MedicsPro if I am under investigation or suspended by my professional regulatory body or employer at any point whilst I am working for Allhands Care. I confirm that when asked about my working history (primarily, but not exclusively, for the purposes of the Agency Workers Regulations) I will provide accurate information.

I have read and agree to the Terms and Conditions and Privacy Policy

Date / Time

Personal/Financial Details Form

Personal Details

Title

Forename(s)

National Insurance No.

Postcode

Surname

Date of Birth (DD/MM/YYYY)

Address:

NEW STARTERS: Please fully complete this form

EXISTING STARTERS: Please only complete the section that you wish to amend

Bank Details

(Please note, if you wish to be paid via Ltd Company Bank Account Information)

Address

Bank/Building Society

Bank Address

Town/City

Postcode

Account Name Exactly as it appears on a Bank Statement

Sort Code (6 digits)

Account Number

Roll No. (If applicable)

Date / Time

The recruitment process within this organisation has a minimum of two stages.