Application Form

1Application Form

Job Details

Job Reference No:

(Optional)

Work Preference:

Part Time
Full Time

Minimum hours available to work:

Total hours per week

Maximum hours available to work:

Total hours per week

Personal Details

Title *

Name *

First

Last

Enter your full name

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Nationality *

Email *

Phone *

Date of Birth *

National Insurance Number *

Do you hold a full UK Driving Licence? *

Do you have access to a car during work hours?

Do you have business insurance?

Are you entitled to work in the UK? *

Please detail your current immigration status and the relevant visa currently held. *

Example: Student Visa, Spouse Visa

Briefly explain what area you have specialised in previously?

For nurses please provide NMC pin and date of expiry

What is the role are you applying for?

Other (Please specify below)

Upload CV

Click or drag a file to this area to upload.

How many years of experience do you have as Health Care Assistant / Nurse?(Current Role) *

MINIMUM 6 MONTHS OF UK EXPERIENCE AS HCA OR AS NURSE IS NEEDED

Have you ever been dismissed or requested to resign from any previous employment?

If yes please provide details below.

Employment History

3 years of Employment history is required.

Job Title

Employer's Details

From

Reasons for Leaving

Brief Description of Duties Undertaken:

Additional Employment History

Job Title

Employer's Details

From

Reasons for Leaving

Brief Description of Duties Undertaken:

Education Details

Year of study

University/School/Collage

Qualification

Have you attended any training courses?

Mention the type of training or certifications attended.

Upload your certificate here (Optional)

Click or drag a file to this area to upload.

References

Please provide names, addresses and telephone numbers for referees below whom we may approach for a reference.

Referee 1

Contact Name *

First

Last

Business Name:

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Capacity in which known *

Referee 2

Contact Name *

First

Last

Business Name:

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Capacity in which known *

Next of Kin Details

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Safeguarding / Ex-Offenders Declaration:

The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. Ramsy Health Care Ltd undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country? *

Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country? *

Answering 'yes' to the question above will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

Health Information

Doctor's Name

Practice Name

Address

Telephone Number

Covid Risk Assessment

Are you fully vaccinated against COVID-19?

Are you able to evidence your vaccination or exemption status using the NHS COVID pass?

Night Workers Declaration

This declaration is to excess if you have any health conditions that may affect your ability to person night work. This assessment is now a requirement of the Working Time Regulations Act 1988.

Do you have any health factors that may affect your fitness to do your night work?

DECLARATION: *

I declare that the foregoing statements are true and complete to the best of my knowledge

Signed:

Date

Name *

First

Last

Criminal Conviction Form

If your application is successful and you take up employment with us, it is possible that you will be asked to verify the information given here by obtaining a Criminal Records Bureau Disclosure.

Name *

First

Last

Are you registered with any professional bodies?

Have you been subject to any kind of investigation/suspension by either an NHS body, or other wider public sector body, or their relevant professional and regulatory body?

Are you subject to any kind of investigation or prosecution relating to a conviction, or which could lead to a conviction since your most recent criminal record check was undertaken?

Do you have any unspent/spent criminal convictions?

Declaration:

This information given by me in this form is to the best of my knowledge and belief, and it is true and correct. I also understand that any misrepresentation by me will lead to the withdrawal of any offer of employment, or my employment being terminated without any obligation of liability on the part of the employer other than for services rendered. I also confirm that if I become subject to an investigation by my professional body or a matter in which could lead to a conviction, I will let the agency know straight away.

Signature

Date:

Note:

*Certain types of employment and professions are exempt from the Rehabilitation of Offenders act 1974, and in those cases particularly where the employment is sought in relation to positions involving working with children or vulnerable adults, details for all criminal convictions must be given. The information given will be treated in the strictest of confidence and only taken into account where, in the reasonable opinion of Ramsy Health Care Ltd, the offence is relevant to the post to which you are applying. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment I the offence is not declared but later comes to light.

Disclosure of Criminal Background

Due to the nature of the service we provide, all offers of employment will be subject to a satisfactory enhanced disclosure via the Disclosure and Barring Service (DBS). The post for which you are applying does not entitle you to rely on the Provisions of the Rehabilitation of Offenders Act 1974. All previous convictions must be disclosed. If you disclose that you have a criminal conviction, and your application is successful, this will be discussed in confidence at interview. If you do not disclose any convictions you have then this may result in your application being rejected, or any conditional job offer you have received being withdrawn. If you are appointed, this non-disclosure may later lead to your dismissal. Any applicants who disclose convictions will be treated fairly, and will be provided with the opportunity to evidence their suitability for the post for which they are applying. Any information provided will be kept confidential, and will only be used in relation to your application. Only convictions relevant to the post for which you are applying will be taken into account.

DBS Check

In order to work for Ramsy Health Care Ltd, you are required to carry out a DBS check with us (if you do not have a valid one already). The cost of this is £60.00. Please provide the following information in order to complete your CRB check:

Previous Addresses for the last 5 years

From

Declaration:

I give consent for Ramsy Health Care Ltd to complete a DBS check along with my application documents.

Signature:

Date

Confidentiality Agreement

I *

confirm that during every assignment and afterwards I understand the importance of: Holding information relating to the client in the strictest confidence, ensure it is kept safely and securely when not in use. I acknowledge that no information is to be removed from the client’s premises without the permission of the Client. Using such information on for the purpose of the work for which it was given. You must under no circumstances disclose any entry codes, security procedures, keep or make copies of any key’s for any placement to any third parties without the express permission of the place of work, and Ramsy Health Care Ltd. Under no circumstances must you use foul language, disruptive behaviour, use mobile phones during contracted hours, or sleep during contracted work hours, even during breaks. Please remember all candidates must always act professional and respect the wishes of the staff and clients. Not disclosing to any third party or copy the information except as is required in the course of my duties. Any breach, either by me or third party, may result in legal proceedings being brought by the Client against me to recover any losses that occurred as a result of a breach.

Name *

First

Last

Date

Health Declaration *

I can confirm that if I do become injured, diagnosed with any medical conditions or become pregnant I will let the agency know straight away so they can undertake necessary provisions and ensure that I am not exposed to any work conditions which could cause risk.

Signature:

Date:

Permission to work in the UK

Do you have immigration permission to work in the UK? *

In line with UKBA guidance on the prevention of illegal working we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by Ramsy Health Care Ltd for work.

48 Hours Opt Out Agreement

I agree that I may work for more than an average of 48hours a week. If I change my mind, I will give my employer (Months) notice in writing to end this agreement.

Signature

Date

Audit Consent

If you are successful in your application, your documents may be required for auditing purposes.

Consent

I confirm that I give permission for my file to be audited by a third-party company.

Code of Conduct (Must Read)

Please follow the link to read the Code of Conduct

Signature

Date

You are signing this form as confirmation that you have read and fully understood our Code of Conduct. By signing this you are taking full responsibility for yourself regarding any breach of this contract. If a breach of contract has been made you will be subject to a disciplinary hearing so, please make sure you have fully understood the document. Incomplete forms may be returned and may delay in offering you agency work.

Availabilities

Please tick which days you are available

Monday

Day
Night

Tuesday

Day
Night

Wednesday

Day
Night

Thursday

Day
Night

Friday

Day
Night

Saturday

Day
Night

Sunday

Day
Night

ALL SUCCESSFUL CANDIDATES SHOULD COMPLETE THE DECLARATION BELOW.

Declaration *

I hereby declare that to the best of my knowledge and belief all the information I have provided in this application form is true and correct. I understand that providing incorrect information or deliberately concealing any relevant information, may result in disqualification from the selection process, or any conditional job offer you receive being withdrawn. If you are appointed, this may later lead to your dismissal.

Signature *

Date *

Application Form

Job Details

Personal Details

Employment History

Additional Employment History

Education Details

References

Referee 1

Referee 2

Next of Kin Details

Safeguarding / Ex-Offenders Declaration:

Health Information

Covid Risk Assessment

Night Workers Declaration

Criminal Conviction Form

Note:

Disclosure of Criminal Background

DBS Check

Confidentiality Agreement

Permission to work in the UK

Audit Consent

Code of Conduct (Must Read)

Availabilities

ALL SUCCESSFUL CANDIDATES SHOULD COMPLETE THE DECLARATION BELOW.

If you are happy with all the information provided, Please click the submit button below to Finish the application form.