Employment Application Form

1 Step 1

Section 1 of 10

Personal details

Title

MrMrsMissMsOther

First Name

Middle

Last Name

Gender

Date of Birth

Phone Number

Address

Postcode

Section 2 of 10

Next of Kin

First Name

Middle

Last Name

Relationship

Phone Number

Address

Postcode

Section 3 of 10

Employment details

Currently working as

Band 1Band 2Band 3Band 4Band 5Band 6Band 7Band 8

Professional registration

RGNRCNRMNRMRNLDODPOther

Confirmation of work experiencePlease confirm which areas you have worked in the past 12 months:

HospitalCommunityPrisonResidentialNursing homeCare in the home

NMC/HCPC Pin number:

Union Membership Number:

Expiry Date of Union Membership:

Union Name:

Section 4 of 10

EDUCATION / QUALIFICATION DETAILS:

Please provide details of relevant professional qualifications

1) Qualification/Certification, Place of Study, Grade/Result and Year CompletedPlease separate each answer with a comma. For example: BSc;, University of London, First class, and year 2020.

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2) Qualification/Certification, Place of Study, Grade/Result and Year CompletedPlease separate each answer with a comma. For example: BSc;, University of London, First class, and year 2020.

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3) Qualification/Certification, Place of Study, Grade/Result and Year CompletedPlease separate each answer with a comma. For example: BSc;, University of London, First class, and year 2020.

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Section 5 of 10

CRIMINAL RECORDS CHECK

DBS Update Service: If you are currently subscribed to the DBS Update Service, do you give us permission to check the certificate?The role(s) you are applying for will require a Disclosure and Barring Service (DBS) enhanced check or Protective Vulnerable Groups (PVG) Scotland check prior to and annually thereafter, for work in Regulated Activity with vulnerable adults and/ children. Rehabilitation of Offenders Act and Unspent Criminal Convictions: The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) Exceptions Order 1975 (2013), (2016 Scotland) provide those certain spent convictions and cautions are ‘protected’ and are not subject to disclosure to employers and cannot be taken into account. Guidance and criteria on the protective filtering of cautions and convictions can be found by contacting the disclosure service.

YesNo

POSITIVE DISCLOSURES CONFIRMATION:Failure to declare information that is later found to be held on your DBS or PVG, may require us to exclude you from our register, discontinue your application, or terminate an assignment if an offence is not declared but later comes to light. Any information given will only be considered in relation to your application for regulated activity positions with our clients and will be managed in accordance with the DBS Code of Practise and Disclosure Scotland code of Practise for PVG. If applying to work in England and/or Wales (DBS): Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013).

YesNo

DECLARING POSITIVE DISCLOSURES / CRIMINAL ACTIVITY:If you have answered yes to the section as above, then please complete the following; I understand AMHC will require further information to assess my application and suitability for roles with clients. If my application is progressed I hereby give AMHC permission, to share the content of my DBS/ PVG certificate with clients/organisations for the purpose of securing temporary work for me. tick the above box if you agree.

I agree

Section 6 of 10

APPRAISAL DETAILS

Date of Appraisal

Name of Appraiser

EMPLOYMENT HISTORY

Employer Name 1 (Current / Most recent Employer)

Start Date

End Date

Job Title

Role/ Responsibilities

Reason for Leaving

Section 7 of 10

REFERENCES: Provide details of your current / most recent employers to contact for a professional reference

Full Name:

Organisation Name:

Referee’s position:

Phone Number

Address

Postcode

Section 8 of 10

INVESTIGATIONS, TERMINATIONS & FITNESS TO PRACTICE:

If you are applying for a post that requires professional registration you are required to provide the following information: Have you ever been suspended or terminated from a Health or Social Care role?

YesNo

Are you currently the subject of a fitness to practise investigation or proceedings by a licensing, regulatory body or other organisation in the UK or in any other country?

YesNo

Have you been removed from the register or have any conditions been made on your registration by a fitness to practice committee or the licensing or regulatory body in the UK, or in any other country?

YesNo

If you have answered yes to any of the above questions, then please provide further details:

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WORKING TIME REGULATIONS 1998:

The European Union has laid down guidelines for all workers, governing the length of the maximum working week that is safe to work. The current limit is 48 hours per week. You are under no obligation to accept any work offered, and you will not be compelled to work more than 48 hours per week, however you may choose to do so. A full explanation of the Working Times Regulations 1998 can be found in your Staff Handbook.

Please select as appropriate:

I do NOT wish to work more than 48 hours per week. Due to the nature of temporary work, I understand the AMHC cannot monitor work patterns outside of AMHC’s control and therefore it is my responsibility to monitor this.I DO wish to work more than 48 hours per week.

DATA PROTECTION:

Legal Compliance: I understand that AMHC retains the right to hold this application and any other data, including data that is considered ‘personal’ and/ ‘special’ that is required to process for the purpose of complying with their legal obligations of my recruitment and supply to suitable assignments with contracted clients, and to retain these details for as long as reasonably necessary in accordance with the General Data Protection Regulation (GDPR)(Regulation (EU) 2016/679) and our contractual obligations.

I consent to AMHC processing data outside of the European Economic Area (EEA) in their secure processing Centre in IndiaPlease Note: If consent is not given for processing your data outside the EEA, we will be unable to progress your application and will destroy all records held

YesNo

MARKETING CONTACT PERMISSIONS:

As part of our service, we would also like to offer you relevant professional information, including:

Useful news and features about your profession
Events, competitions, and promotions we are running
Surveys and opportunities for you to offer your views and insights
Ongoing career opportunities during breaks of 12 months or more from temporary work assignments with us.

WORKING HOLIDAY ENTITLEMENT CLAUSE:

Working holiday entitlement clause:Whilst working for the agency, the temporary worker will accumulate Holiday Pay calculated as a percentage of the hourly rate of pay. We co-ordinate leave from April to April. All requests must be made within the correct time period. Should you submit request later than 31st March you will no longer be entitled to holiday pay for the previous year. If applying for holidays, the temporary worker must give a minimum of 1 weeks’ notice to the Registered Manager or Sales Manager at the agency. I have read, understand, and will comply with the Working Holiday Entitlement Clause. For the purposes of your employment with us, the holiday year will be the 12-month period commencing on the 6th April (and, if applicable, each subsequent 12 month period). All entitlement to leave must be taken during the holiday year in which it accrues, and none may be carried over into the next holiday year. The agency is not required by law to make any payment in lieu of unused holiday at the end of the holiday year. When making your holiday plans please observe the following: You should not normally plan to take more than two weeks at any one time although a longer period may be granted in special circumstances. Notice must be given of either 1 week or equivalent to the total length of the holiday, whichever is the greater.

I agree

Section 9 of 10

PAYMENT DETAILS:

Please confirm your preferred method of payment (Umbrella Company):Subject to approval by AMHC prior to payment method being approved. Umbrella companies are required to comply with IR35 guidelines. Please check with your consultant if you Umbrella company meets these requirements.

My Weekly PayDanbro Accounting LTDJSA Services LTDGiant ProfessionalOther

Please confirm that you agree to the terms and conditions of the above selected Umbrella company:

Understand that registration with my chosen Umbrella company is my responsibility and that a delay in registration may delay payment.

I agree

Consent to AMHC sharing your personal details with your chosen Umbrella company for payment for work completed.

I agree

PAYE – Please provide your bank details.

Payee Name as it appears on your account

Account Number

Sort Code

Section 10 of 10

DECLARATIONS: By applying to AMHC, I confirm that:

Security Checks In line with the nature of the work I will be undertaking, I understand that there will be necessary security checks carried out, including but not limited to electronic identity checks; and I consent to this.

For NMC/HCPC Registered Applicants: Regulated Professional Standards of Practise A) I agree to adhere to my Regulated Professional Standards/Code of Practise, always including associated Medication Administration Standards whilst on placement through AMHC. B) I agree to immediately inform AMHC if I am under investigation or have conditions or changes to my registration sanctioned my professional regulatory body.

Investigations, suspensions, terminations and criminal activity I agree to immediately inform AMHC if I am under investigation, suspended or terminated from a place of work a. I agree to immediately inform AMHC if I am under investigation by the police, safeguarding authorities or other third-party organisation/s, or have convictions or cautions added to my DBS.

Staff Handbook I have received and read a copy of the Staff Handbook. I understand all the policies and procedures and will always abide by the code of conduct.

Client Policies and Induction I will follow client policies and procedures and ensure I receive an induction at the placement site.

Compliance Updates I understand that during the course of my engagement with AMHC, my compliance and documentation may require updating from time to time. I agree to comply with these requirements as necessary and within the timelines given to prevent delays on work being offered.

Fitness to work A) I will ensure that I am healthy and fit to work shifts offered to me B) I understand that my FTW status may be shared with clients for the purpose of securing temporary work assignments for me. C) If my health changes from the information provided in my initial or annual Health Questionnaires, I will immediately inform AMHC.

Audit Consent In line with the nature of the work I will be undertaking, I understand that the documentation I have provided in adherence with compliance procedures, may be audited in relation to the provision of the services at any time and I consent to this.

I hereby give permission for Agape Medical Health Care Ltd to allow access, as a minimum, to my personnel files as part of any official audit, or client compliance purposes, carried out by, but not limited to, HTE, CPP and CCS and/or any person authorised by the NHS Authority. These personnel files will be viewed in accordance with the requirements of the Data Protection Act 1998.

TICK BELOW IF YOUR AGREE TO THE ABOVE DECLARATIONS

I agree

Signed by the Temporary Worker

[Print name here]

Date