Career Application Form

Personal Details
Title:
Full Name:*
Job Title:
Date of Birth:*
Known By Any Other Name (From and To):
Address*
Street Address City Post Code Country
Home Telephone:
Mobile Telephone:*
Nationality:*
Email Address:*
Martial Status:
National Insurance Number:*
Do you hold a current driving licence?:*
Checklist
In order to process your application smoothly, please ensure you enclose ALL documents/information as detailed below, where applicable with your application. - Last 3 years’ worth of references or 2 most recent and relevant. 1 must be most recent employer - Qualifications and Certificates (Professional Registration Certificate, Degree and BLS/ALS/PALS certificate as appropriate) - Immunisation history - Current DBS Disclosure *Must be registered on the Update Service - Overseas Police Check/Certificate of Good Conduct (if you have been outside the UK for more than 3 months over the past 5 years) - Proof of National Insurance Number - 2x Proof of current address - Eligibility to work in the UK *For information regarding right to work documents in the UK please visit www.gov.uk or contact your consultant - Professional Medical Indemnity Certificate *Nurse Only - 2x Passport photographs (For ID Badge, once fully registered)
Next of Kin Details:
Next of Kin Name:
Relationship:
Address
Street Address City Post Code Country
Telephone Number:
Email
Payment Information
Payment Frequency: Monthly
Card Holder's Name:*
Bank Name:*
Account Number:*
Sort Code:*
Professional Registration
Nurse/Midwife Only
Position Applied For:
Main Specialism:
NMC Registration Number:
Renewal Date:
Appraisal Management:
Revalidation is the new process that all nurses and midwives in the UK will need to follow to maintain their registration with the NMC. Taking effect from April 2016, revalidation is straightforward and will help you as a nurse or midwife demonstrate that you practise safely and effectively. It will encourage you to reflect on the role of the Code in your practice and demonstrate that you are 'living' the standards set out within it. Please confirm that you are aware and are putting plans in place.
Name of Nominated Appraiser:
NMC Registration Number:
Contact Details:
Medical Indemnity Insurance
Nurse/Midwife Only
Name of Insurer:
Policy Number:
Expiry Date (if applicable):
Reference Details
Please disclose last 3 years’ worth of referee details or 2 recent and relevant references - 1 from most recent employer. All referee details must be from a person in a more senior/managerial position. (We reserve the right to contact all previous employees)
Referee Name:
Position:
Name of Organisation/School/College:
Telephone Number:
Email Address:
Start Date:
End Date:
Reason for Leaving:
Referee Name:
Position:
Name of Organisation/School/College:
Telephone Number:
Email Address:
Start Date:
End Date:
Reason for Leaving:
Referee Name:
Position:
Name of Organisation/School/College:
Telephone Number:
Email Address:
Start Date:
End Date:
Reason for Leaving:
Referee Name:
Position:
Name of Organisation/School/College:
Telephone Number:
Email Address:
Start Date:
End Date:
Reason for Leaving:
Fitness to Work
Do you have any issues that would impact your ability to undertake your assignment or do you require any additional support?:*
If 'yes', please provide details:
Qualifications/Mandatory Training
Qualifications:
Mandatory Training:
- Basic/Advanced Life Support *Practical
- Personal care
- Complaint Handling
- Countering Fraud and Bribery in the NHS
- COSHH
- Equality, Diversity and Inclusion
- Fire Safety
- Food Hygiene
- Handling Violence and Aggression
- Handling Medication *Nurse Only
- Infection Control
- Information Governance
- Lone Worker
- Mental Capacity Act 2005
- Mental Health Act 2007
- Manual Handling *Practical
- RIDDOR
- Safeguarding Adults and Children
Care Pack Training:
- Communication
- Consent
- Dementia Awareness
- Duty of Care
- Fluids and Nutrition
- Preventing Radicalisation
- Privacy and Dignity
- Promoting Person-Centred Approach
- Your Health Career
Safeguarding
Disqualification from Caring for Children Regulations 2002
In accordance with the Disqualification from Caring for Children Regulations 2002, have you ever had a child removed from your care?:*
If 'yes', please provide details:
Declaration of Criminal Convictions: Have you, at any time, received, or had pending, a court conviction in the UK or overseas?:*
In order to protect certain vulnerable groups with society, there are a number of posts and professions that are exempt from the provisions of the Rehabilitation of Offenders Act 1974. These include posts where in the normal course of duty, employees have access to persons requiring care. Under the Exceptions Order (1975), applicants are obliged to disclose information about any convictions which for other purposes would be regarded as ‘spent’. Failure to disclose such convictions could result in dismissal or disciplinary action by the employing organisation. Any information given will be confidential and will be considered only in relation to any posts to which the conviction applies.
If 'yes', please provide details:
Do you hold a current UK police check (DBS)?:*
If 'yes', please provide the following details: - Disclosure Number - Issue Date - Issued By
Have you subscribed to the DBS Update Service?:*
Please note: If you are not subscribed to the DBS Update Service or do not have a current DBS we will require you to complete a DBS in our name upon commencement of employment through us. For details on how to complete a DBS in our name please contact our office.
Equal Opportunities Monitoring
524 Jobs Limited is an Equal Opportunity Recruitment Agency. We ensure all applicants are submitted for vacancies based solely on the basis of merit irrespective of any characteristics that may place an applicant in any minority or disadvantage group or groups. In order for us to measure the effectiveness of this policy and continue to develop relevant personnel policies, please complete the following questions. Information given is confidential and will only be used for statistical monitoring. It does not form any part of your job application.
Gender:*
Age Group:*
Ethnic Origin:*
Referrals
How did you hear about 524Jobs Limited?:
Was our agency recommended to you by somebody working for 524Jobs Limited? If so, please give details:
If you recommend a qualified friend or colleague to us for Locum work we may pay you a referral fee. Please inquire with your Recruitment Consultant for further details of the offer. Please provide us with names and contact details of anybody you know who may be interested below:
Declaration
The information in this form is true and complete. I understand that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application form or subsequent dismissal if employed by the organisation. I acknowledge that my personal details will be stored and handled by 524 Jobs Limited in accordance with the Data Protection Act 1998. I agree that the company may forward my details to prospective employers in capacity as an agency. I am happy for 524 Jobs Limited to contact me from time to time regarding market research and new opportunities. I authorise 524 Jobs Limited to obtain any relevant references and verification of qualifications on my behalf. I confirm that I am not currently disqualified from working with children or vulnerable adults, or subject to any sanctions imposed by a regulatory or professional body and if these circumstances were to change, I understand I must inform 524 Jobs Limited immediately. Any changes to information on my current DBS that has not already been disclosed will also be disclosed to 524 Jobs Limited immediately. 524 Jobs Limited is able to upload the applicant’s copy of your DBS onto the Vendor Managed Systems (VMS) that currently holds a number of contracts Nationwide in order to gain new employment. I agree for 524 Jobs Limited to conduct Update Service checks against my DBS regularly as part of the safeguarding process. (If applicable) I agree for 524 Jobs Limited to share my application documents for audit purposes.
Working Times Regulations 1998 requires 524 Jobs Limited to ensure all agency workers complete no more than 48 hours work per week. If you wish to opt out of this, please select yes.*
Signature:*
(Type in surname as signature)
Print Name:*
First Last
Date:*

Career Application Form

Career Application Form

Career Application Form

Personal Details

Checklist

Next of Kin Details:

Payment Information

Professional Registration

Medical Indemnity Insurance

Reference Details

Fitness to Work

Qualifications/Mandatory Training

Safeguarding

Equal Opportunities Monitoring

Referrals

Declaration