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SECTION 1 – PERSONAL DETAILS

Country of residence

TITLE (Mr./Mrs./Miss/Ms./Dr): *

Name *

First

Last

PREVIOUS NAME(S)

MOBILE No *

NATIONALITY *

DATE OF BIRTH *

GENDER *

CURRENT ADDRESS *

Address Line 1

City

State / Province / Region

Postal Code

Country

Email *

PROFESSIONAL REG No

PROFESSIONAL BODY

GRADE *

NATIONAL INSURANCE NUMBER *

We are not accepting oversea applications at the moment.

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SECTION 2: WORK PERMIT AND INSURANCE DETAILS

PLEASE GIVE DETAILS OF YOUR VISA STATUS BY CHOOSING FROM THE FOLLOWING *

EU PASSPORT
WORKING HOLIDAY VISA
STUDENT VISA
RIGHT OF ABODE
Others

PLEASE STATE VISA EXPIRY DATE

DO YOU REQUIRE A WORK PERMIT? *

Please upload a copy of your passport & copies of any UK entry stamps or certificates *

Click or drag files to this area to upload. You can upload up to 3 files.

DO YOU CURRENTLY HAVE PERSONAL INDEMNITY INSURANCE? *

COMPANY & POLICY NUMBER *

EXPIRY DATE *

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SECTION 3 – EDUCATIONAL HISTORY

Add all your educational history using the + botton

UNIVERSITY/INSTITUTION *

QUALIFICATION *

START DATE *

END DATE *

PLEASE GIVE DETAILS OF ANY FURTHER QUALIFICATIONS OR TRAINING. Please give dates & places.

Please ensure that you upload a copy of ALL your professional certificates or documents.

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SECTION 4 – EMPLOYMENT HISTORY

PLEASE GIVE DETAILS OF ALL EMPLOYMENT IN THE PAST 5 YEARS.Start with the most recent and cover at least the last five years. All gaps in work history must be accounted for. (Use separate sheet if necessary).

Add all Employment histories

Employer Details *

Start/End date *

Position *

Duties/Experience gained *

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SECTION 5 – MANUAL HANDLING AND TRAINING

DO YOU HOLD TRAINING CERTIFICATES IN ANY OF THE FOLLOWING? (Please tick and provide proof) *

Moving and Manual Handling
Health and Safety
Infection Prevention and Control
Mental Health Act
Basic Life Support
Handling of Violence and Aggression

Add any other Training Certificates you have separating them with comma

SECTION 6 – Professional References

PLEASE SUPPLY DETAILS OF ATLEAST TWO PROFESSIONAL REFERENCES.One reference must be from your most recent employer and at least one reference must be from a department head or above.

Professional References. You can add up to three references

Name *

Email *

Position *

Address *

Sign Your Signature *

Clear Signature

Your Name *

First

Last

Date *

SECTION 7 – WORK REQUIREMENTS

Temporary
Permanent
Both

Available to start work from: *

DO YOU HOLD A VALID FULL UK DRIVING LICENCE? *

DO YOU HAVE REGULAR USE OF A VEHICLE? *

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PLEASE PROVIDE US WITH THE FOLLOWING GENERAL HEALTH INFORMATION. IF YOU ANSWER YES TO ANY OF THE QUESTIONS IN THIS SECTION, PLEASE PROVIDE DETAILS.

HAVE YOU ATTENDED YOUR GP IN THE LAST YEAR? *

If Yes, Why?

ARE YOU CURRENTLY TAKING ANY PRESCRIBED MEDICATIONS? *

IF YES, WHAT MEDICATION AND WHY?

DO YOU HAVE OR HAVE YOU EVER SUFFERED FROM ANY OF THE FOLLOWING MEDICAL CONDITIONS? *

BLACKOUTS / EPILEPSY / DIZZY SPELLS
HEART / CIRCULATORY PROBLEMS
HYPERTENSION
ASTHMA / BRONCHITIS / PLEURISY
TUBERCULOSIS (TB)
ECZEMA / PSORIASIS
DIABETES
MAJOR OPERATIONS / SERIOUS ILLNESS
RHEUMATISM / ARTHRITIS
CHICKENPOX
ALLERGIES (INCLUDING LATEX)
BACK, UPPER LIMB OR NECK INJURY
NERVOUS/MENTAL ILLNESS OR EATING DISORDER
BLOOD DISORDERS/ANAEMIA/HAEMOPHILIA

HAVE YOU EVER BEEN SCREENED FOR VARICELLA/RUBELLA/TUBERCULOSIS/HEPATITIS B? *

If Yes, Upload proof

Click or drag a file to this area to upload.

Your Signature *

Clear Signature

I PROVIDE MY PERMISSION FOR EMPOWER RECRUITMENT LTD TO OBTAIN MY PERSONAL OCCUPATIONAL HEALTH RECORDS AND/OR SIMILAR DATA FROM THIRD PARTIES SUCH AS NHS TRUSTS OR GP DOCTORS FOR THE PURPOSE OF REGISTRATION AND CLEARANCE FOR HEALTHCARE WORK.

Name *

First

Last

Date *

SECTION 9 – PROFESSIONAL CONDUCT

HAVE YOU EVER BEEN THE SUBJECT OF PROFESSIONAL MISCONDUCT PROCEEDINGS, DISCIPLINARY PROCEEDINGS OR DISCIPLINARY ACTION FROM AN EMPLOYER, OR ARE SUCH PENDING OR THREATENED AGAINST YOU EITHER IN THE UK OR ABROAD? *

IF YES PLEASE GIVE DETAILS

SECTION 10 – REHABILITATION OF OFFENDERS ACT

DO YOU HAVE ANY CONVICTIONS OR CAUTIONS? *

The Rehabilitation of Offenders Act 1974 permits persons in certain circumstances to ignore offences committed in the past when asked to give details of previous convictions. These convictions are known as “spent convictions”, however the Exceptions Order of 1975 states that those employed in the medical/care fields are not allowed to withhold details of any offences for which they have been convicted, however long ago these convictions may have been served.

PLEASE DETAIL BELOW ALL CONVICTIONS AND CAUTIONS REGARDLESS OF THE SERIOUSNESS OF THE OFFENCE AND HOW LONG AGO THE CONVICTION OCCURRED:

This information may be shared confidentially and at an appropriate level with prospective employers to enable them to make a recruitment decision.

SECTION 11- DISCLOSURE AND BARRING SERVICE (DBS)

All recruitment agencies and NHS bodies are required by law to ask all applicants to apply for an Enhanced Disclosure, as the job for which you are applying may involve access to children and vulnerable adults. It is therefore exempt from the Rehabilitation of Offenders Act 1974. In order to secure work for you, we require an Enhanced Disclosure that was issued within the last year. If you already hold a Disclosure which is current (within the last year), please forward the original document to us and sign the declaration below. Your Disclosure will be handled securely and returned to you via special delivery. In addition, we will also need to apply for an Enhanced Disclosure for you in our own company name. Full details regarding this process will be provided to you by your Recruitment Consultant or our Compliance Team in a separate communication.

DO YOU HAVE YOUR OWN CURRENT DBS COPY? *

IF YES, PLEASE UPLOAD THE ORIGINAL

Click or drag a file to this area to upload.

SECTION 12- EMERGENCY CONTACT DETAILS

PLEASE GIVE DETAILS OF THE PERSON YOU WOULD LIKE TO BE CONTACTED IN THE EVENT OF AN EMERGENCY

Name *

First

Last

Phone

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Email *

Relationship *

SECTION 13- BANK DETAILS

Bank Name *

Account Name *

Account Number *

Sort Code

SECTION 14- WORKING HOURS

IN COMPLIANCE WITH THE IMPLEMENTATION OF THE WORKING TIME REGULATIONS, EMPOWER RECRUITMENT LTD RECOMMEND THAT WORKING TIME SHOULD NOT EXCEED 48 HOURS PER WEEK (AVERAGED OVER A PERIOD OF 17 WEEKS). HOWEVER, SHOULD YOU WISH TO WAIVE THIS RIGHT, PLEASE INDICATE THIS PREFERENCE BY TICKING BELOW:

YES, I WISH TO WORK MORE THAN 48 HOURS PER WEEK *

You can change your chosen option at any time by giving appropriate notice in writing to Empower recruitment. Working time shall include only the period of attendance at each individual assignment through Empower Recruitment. It shall not include travelling time unless specifically agreed by the Manager.

SECTION 15- GENERAL DATA PROTECTION REGULATION (GDPR) AND CONTACT CONSENT

EMPOWER RECRUITMENT LTD WILL NOT PASS YOUR INFORMATION ON TO ANY OTHER COMPANY

PLEASE TICK THE BOX IF YOU WOULD PREFER NOT TO BE CONTACTED BY NORFOLK AND SUFFOLK HEALTHCARE LIMITED WITH CAREER INFORMATION AND REWARD SCHEMES THAT ARE OF BENEFIT TO YOU

All personal data provided by you (the applicant) will be treated as confidential and stored / managed on our secure servers. We do however require your consent to process and transmit your information to third parties for the purpose of finding you suitable employment and obtaining essential supporting documentation. This consent covers all information we may require whilst representing you; including but not limited to your application, training & compliance, work placements, payroll and general day-to-day correspondence. Temporary work dictates the need for quick, effective communication for us to secure assignments for you. It is therefore essential for us to maintain regular contact with you across multiple channels. This includes phone, Email, SMS and in-app push notifications (where applicable). Your consent is required for us to do so. We take data privacy and security very seriously and your personal information will be processed and secured in accordance with The General Data Protection Regulations (GDPR). Our privacy policy can be viewed on our website.

Do you give consent? *

SECTION 16- DECLARATION

I DECLARE THAT I HAVE READ, UNDERSTOOD AND ACCEPT EMPOWER RECRUITMENT LTD TERMS & CONDITIONS AND CANDIDATE HANDBOOK. I HAVE COMPLETED THIS FORM IN FULL AND ALL THE INFORMATION THAT I HAVE PROVIDED IS CORRECT AND TRUE. I WILL NOTIFY EMPOWER RECRUITMENT LIMITED OF ANY CHANGES TO MY PROFESSIONAL CONDUCT RECORD, FITNESS TO PRACTICE AND CRIMINAL CONVICTIONS STATUS. BY SIGNING THIS DECLARATION, I AGREE TO EVERYTHING HEREIN. AS REQUIRED BY THE DATA PROTECTION ACT, I CONSENT TO EMPOWER RECRUITMENT LTD STORING, PROCESSING AND PROVIDING POTENTIAL EMPLOYERS WITH MY PERSONAL INFORMATION FOR THE PURPOSE OF FINDING ME WORK PLACEMENTS. I UNDERSTAND THAT ANY PERSONAL DATA HELD BY EMPOWER RECRUITMENT LIMITED IS LIABLE TO BE INSPECTED BY CLIENTS, GOVERNMENT PROCUREMENT SERVICES (GPS) AND OTHER THIRD PARTY ORGANISATIONS AS PART OF AUDIT PROCEDURES AND PROVIDE MY PERMISSION FOR EMPOWER RECRUITMENT LIMITED TO DISCLOSE ALL OR ANY ELEMENT OF MY PERSONAL DATA FOR THIS PURPOSE.

Signature *

Clear Signature

Date *

Name *

First

Last

Upload all your supporting documents *

Click or drag files to this area to upload. You can upload up to 20 files.

Tick all the documents uploaded *

Trainings
A copy of your most up to date CV.
Proof of Address
Proof of NI
Recent passport Photograph
A copy of your most recent CRB Certificate (DBS)
Right to work sharecode
BRP
Other

If other, Please specify

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