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Application Form

Personal Data:

First Name*

Last Name*

Email Address*

Phone Number*

Date Of Birth (Click on the calendar icon)*

National Insurance Number*

Address*

Work Eligibility:

* Eligibility to work in the UK & Ireland: You must bring the original documentation if invited to an interview as evidence of your entitlement to work in this country. Failure to do so will invalidate your application. Please confirm which of the following you have:

British Passport or UK birth certificate & letter

Passport showing right to live & work in the UK

Non-European passport with relevant work visa

Certificate of registration / naturalization as a British Citizen

EEC passport or identity card plus required work registration letter

Any other document that supports your eligibility to work in the UK

Work Availability:

How many hours are you looking to work?

Where would you like to work?

The Really Important bit…… Working in health and social care means we need to pass enhanced checks. Because of this you are required to disclose all spent and unspent convictions, cautions, reprimands and warnings under the Rehabilitation of Offenders Act 1974 exemption. Please be aware that some convictions although spent may still appear on your DBS/PVG check. Please answer this section honestly if you are in any doubt whatsoever about making a declaration then please discuss with the Agency manager. You are required under the Act to inform us if you are convicted of a criminal offense, cautioned or have a hearing pending in the future.

* A conviction does not automatically prevent you from working for us, however failure to declare or providing inaccurate information will be taken into consideration when reviewing your disclosure. If you are successful in your application you have a responsibility to update your disclosure status. We actively promote equality of opportunity for all, as stated in our Equal Opportunity policy which is available upon request.

Awareness Allegations:

* Are you aware of any recent/outstanding allegations/investigations that have been made against you that relate to any safeguarding issue/referrals including any referrals to the Nursing Medical Council, Disclosure & Barring Service (DBS) or Protection of Vulnerable Groups Scheme (PVG)?

Yes

* Do you have any spent or unspent convictions, cautions, reprimands or warnings?

Yes

* Do you have any pending or unresolved disciplinary action taken against you, either in employment or care related activity?

Yes

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