Please fill in the Application form, which is split into three parts. Please complete the form and check it carefully before returning it to the address or by email below. Please note that questions marked with an asterisk * are mandatory and therefore must be answered.
Details entered in this part of the form will be held in the HR department of the recruiting organisation.
May we contact you at work?*
Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National?*
Do you have leave to enter/remain and the right to work in the United Kingdom (UK)?*
Please select the category that relates to your current immigration status. This status will be subject to checking before interview.*
Highly Skilled Migrant Programme
Work Permit
Dependant/Spouse Visa
Clinical Attachment Visa
Visitor
Post Graduate Doctors and Dentists
Leave to Remain/Enter
Working Holiday Visa
Refugee
Other, please specify below
If you have a disability, do you require any specific arrangements to enable you to attend for interview?*
This section of the application form will be detached from your application form and will be used for monitoring purposes only.
Nashe Healthcare Recruit recognise and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community.
Race relations (Amendment) Act 2000
I would describe my ethnic origin as:*
Asian or Asian British
Black or Black British
Mixed
White
Other Ethnic Group
Employment Equality Regulations 2003
Please select the option which best describes your sexuality*
Please indicate your religion or belief*
The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions to employers after the rehabilitation period set by the Court has elapsed and the convictions become 'spent'. During the rehabilitation period, convictions are referred to as 'unspent' convictions and must be declared to employers.
Before you can be considered for appointment we need to be satisfied about your character and suitability.
Nashe Healthcare Recruit aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation, or age. Nashe International Recruitment Agency undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.
Have you any unspent criminal convictions or bind overs, or any cautions, warnings or reprimands?*
You are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory disclosure from the Criminal Records Bureau. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment.
The information in this form is true and complete. I agree that any deliberate omissions, falsification, or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This applies equally to any medical questionnaire/forms I may complete.
I agree to the above declaration
Where did you see this vacancy advertised?
Nashe Healthcare Recruit Website
Search Engine
Other Website
National Newspaper
Local Newspaper
Jobcentre Plus
Radio
Other
Include in this section all the relevant qualifications. Please also indicate subjects currently being studied.
Subject/Qualification
Place of Study
Grade/result
Year
Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking.
Course Title
Training Provider
Duration
Date Completed
Include in this section any relevant professional registrations or memberships.
Please indicate your Professional Registration status:*
Not Required for this post
I have current UK registration
UK registration applied for
UK registration not yet applied for
I am a student
If professional registration is not required then go to Employment History.
If you are registered, then please enter the relevant details below:
Professional Body
Membership or Registration type
Membership/Registration PIN
Expiry/Renewal Date
If you are applying for a post that requires professional registration you are required to provide the following information:
Are you currently the subject of a fitness to practise investigation or proceedings by a licensing or regulatory body in the UK or in any other country?*
Have you been removed from the register or have conditions been made on your registration by a fitness to practise committee or the licensing or regulatory body in the UK or in any other country?*
Please record below the details of your current or most recent employer
Please record below the details of your previous employment beginning with the most recent first. Please explain any gaps in employment in the 'Supporting Information' section below.
In this section please give your reasons for applying for this post and additional information which shows how you match the requirements of the post you are applying for. This can include relevant skills, knowledge, experience, voluntary activities and training etc.*
Preferred Shift Times*
Do you have a valid driving licence for the UK?*
Do you have access to a vehicle which can be used for work purposes?*
Please give the names of the people who have agreed to supply references. For all positions you must provide 2 references. If you are, or have been employed, these should be your two most recent employers. These may include your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities, and suitability for the post. If you are a student please provide contact details of a teacher at your school, college or university. Please note that personal references such as friends and relatives are not acceptable. For all posts written references obtained must cover the preceding 3 years of employment. All referees will be approached prior to interview unless you indicate otherwise.
Can the referee be contacted prior to interview?*
Can the referee be contacted prior to interview?
All questions contained in this questionnaire are strictly confidential and will become part of your employment record.
Marital status:*
GP Details
Childhood illnesses
Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio
Immunizations and dates:
Tetanus
Hepatitis
Influenza
Pneumonia
Chickenpox - Past History
MMR Measles, Mumps, Rubella
Tetanus Date
Hepatitis Date
Influenza Date
Pneumonia Date
Chickenpox - Past History Date
MMR Measles, Mumps, Rubella Date
Have you been tested to MRSA (methicillin Resistant Staph Aureus)?*
Have you had skin complaints? EG. Dermatitis, Eczema, Psoriasis*
Do you have vision or hearing loss?*
Have you had any heart problems?*
Have you had any bowel infections?
Do you have any Allergies?*
Do you have Diabetes?*
Have you had any Liver Problems?*
Have you had any Lung problems?*
Have you ever suffered from Black outs?
Have you ever had any mental health problems?*
Have you ever had back/mobility problems?*
Have you ever had any joint problems?*
Have you ever had any other infections?*
Have you ever been refused a job on health grounds?*
Have you been sick for work for more than 2 weeks?*
I understand that giving false information with regards to my medical history and fitness may lead to termination of my contract and services.To the best of my knowledge the above information is correct.
Warning: Your DBS check will not be completed if this form is not filled in.It is your responsibility to fill this form in before beginning the registration process.
Please write below your address history for the last five years if different from your current address.
If your Forename or surname, has changed at any point throughout your life, please detail those changes and the dates on which they occurred below:
List of Valid Documents that can be used as evidence of identity for DBS purposes:
Route 1
1 document from Group 1 (refer to list of Valid Identity Documents); and or 2 further documents from Group 1, 2a or 2b; one of which must verify your current address.
NOTE – For EEA Nationals (Non-UK): Where an EEA National has been resident in the UK for five years or less, the identity will be validated via Route One through the checking of a current Passport or current UK Driving License (photo card only) plus 2 further documents.
ALL UK NATIONALS WILL BE VALIDATED VIA ROUTE 1 ONLY
Route 2
3 documents from Group 2 comprising of;
Route 3
Birth certificate (UK and Channel Islands) – (issued after the time of birth by the General Register Office/relevant authority i.e. Registrars – Photocopies are not acceptable) and or 4 further documents from Group 2 comprising of:
If you are successful you will be required to provide relevant evidence of the above details prior to your appointment.
In case of emergencies it is vital that Nashe Recruitment have these details on file. If any details change in the future then contact Nashe Recruitment to change them.
You need to tick only one box of the following statement*
Student Loan
I have a student loan which is not fully paid and I left a course of Higher education before last 6th April and I received my first student loan instalment on or after 1st September 1988.
Select no if you are paying your student direct to the student loans company by agreed monthly payments.*
List of attachments to accompany your submission:
I can confirm the above information is correct.
