Application Form Please enable JavaScript in your browser to complete this form.1Application Form2345678910111213Job DetailsJob Reference No:(Optional)Work Preference:Part TimeFull TimeMinimum hours available to work:Total hours per weekMaximum hours available to work: Total hours per weekPersonal DetailsTitle *MrMissMrsMsName *FirstLastEnter your full nameAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryNationality *Email *Phone *Date of Birth *National Insurance Number *Do you hold a full UK Driving Licence? *YesNoDo you have access to a car during work hours?YesNoDo you have business insurance?YesNoAre you entitled to work in the UK? *YesNoPlease detail your current immigration status and the relevant visa currently held. *Example: Student Visa, Spouse VisaBriefly explain what area you have specialised in previously? For nurses please provide NMC pin and date of expiryWhat is the role are you applying for?HCASenior CarerRGN - Registered NurseAdminChefKitchen AssistantCleaningOtherOther (Please specify below)Upload CV Click or drag a file to this area to upload. NextHow 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 NEEDEDHave you ever been dismissed or requested to resign from any previous employment? YesNoIf yes please provide details below. Employment History3 years of Employment history is required.Job TitleEmployer's DetailsFromToReasons for LeavingBrief Description of Duties Undertaken:Additional Employment HistoryJob Title Employer's Details From ToReasons for Leaving Brief Description of Duties Undertaken:NextEducation DetailsYear of studyUniversity/School/CollageQualificationHave you attended any training courses?YesNoMention the type of training or certifications attended.Upload your certificate here (Optional) Click or drag a file to this area to upload. NextReferencesPlease provide names, addresses and telephone numbers for referees below whom we may approach for a reference.Referee 1 Contact Name *FirstLastBusiness Name:Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone *Email *Capacity in which known *Referee 2Contact Name *FirstLastBusiness Name:Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone *Email *Capacity in which known *NextNext of Kin DetailsName *FirstLastAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhoneNextSafeguarding / 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? *YesNoDo you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country? *YesNoAnswering '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.NextHealth InformationDoctor's NamePractice NameAddressTelephone NumberCovid Risk AssessmentAre you fully vaccinated against COVID-19?YesNoAre you able to evidence your vaccination or exemption status using the NHS COVID pass?YesNoNight Workers DeclarationThis 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?YesNoDECLARATION: *I declare that the foregoing statements are true and complete to the best of my knowledgeSigned:DateNextName *FirstLastCriminal Conviction FormIf 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 *FirstLastAre you registered with any professional bodies?YesNoHave 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?YesNoAre 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?YesNoDo you have any unspent/spent criminal convictions?YesNoDeclaration: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.SignatureDate: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.NextDisclosure of Criminal BackgroundDue 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 yearsFromTo Declaration: I give consent for Ramsy Health Care Ltd to complete a DBS check along with my application documents.Signature:DateNextConfidentiality AgreementI *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 *FirstLastDate NextHealth 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 UKDo you have immigration permission to work in the UK? *YesNoIn 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.Next48 Hours Opt Out AgreementI 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.SignatureDate Audit ConsentIf you are successful in your application, your documents may be required for auditing purposes.ConsentI 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 ConductSignatureDate 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. NextAvailabilitiesPlease tick which days you are availableMondayDayNightTuesdayDayNightWednesdayDayNightThursdayDayNightFridayDayNightSaturdayDayNightSundayDayNightALL 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 *If you are happy with all the information provided, Please click the submit button below to Finish the application form.PreviousSubmit