Application Form

Position Applied For: *

Personal Details *

Mark a appropriateMrMrsMissMsDr

Name & Surname *

Date of Birth *

National Insurance *

Email *

Telephone number

Mobile

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Nationality *

Passport Number

Please tell us about your eligibility to work in the UK *

I am eligible to work in the UK and do not require a work permitI am already in possession of a work permit to work in the UKI need to obtain a work permit to work in the UKOther

If Other please specify

Do you hold a valid UK Driving Licence?

YESNo

Do you own a car?

YESNO

How far are you willing to travel for work?

Professional Qualifications

Qualification, Year obtained, Professional Body e.g. NMC,GMC etc, Registration Number

Employment History

Please supply details of your full employment history and explain any gaps in your history. Continue on a different sheet if required.

Job Title

Employer

Date from

Date to

Reason for leaving

Clinical Skills (applies only to nurses)

Please place a tick next to options with the clinical area you have expertise in:Option 1: A&E• Endoscopy• HDU• ITU• Mental Health• NICU• Occupational Health• Chemotherapy• Paediatrics• Practise Nurse• Recovery• SCBU• Triage• CommunityOption 2: Cardiac• Diagnostic Imaging/x-ray• General Wards• Health Visitor• Learning Disabilities• Midwifery• Nurse Practitioner• ODP• Orthopaedics• Palliative• Prison• Renal• Surgical• UrologyOption 3: Clinics• Elderly Care• Gynaecology• Homecare• Medical• Neonatal• Nursing Homes• Oncology• Paediatric A&E• Paediatric ICU• Radiology• Dialysis• Theatre• Walk in centre

Professional Conduct

Have there ever been any proceedings of medical negligence or professional misconduct, allegations of misconduct against you and have you ever been suspended or dismissed?

If YES please supply details below

Rehabilitation of Offenders Act

Because of the nature of the work for which you are applying, Section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 applies. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the order applies. All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected. Have you at any time been convicted of an offence?YESNO

If YES, Please supply details below

Next of Kin Details *Name and Surname

Relationship to you

Daytime Telephone Number

Mobile number

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

References - One of these must be your curre nt or most recent employer Please supply the names and work addresses of at least 2 clinical professional referees. One must be of a senior grade than you.

Position ref

Email

Day time Telephone number

Mobile number

Position

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

How long has this person known you for?

Reference 2: Name

Position ref

Email

Day time Telephone number

Mobile number

Position

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

How long has this person known you for?

Declarations, Terms & Conditions

I certify that the information contained on this application form is accurate and true. I understand that my registration is subject to the receipt of at least two satisfactory references and enhanced disclosure from the Criminal Records Bureau. I undertake to inform Sabaoth Care Ltd should I be convicted of an offence in the future. I undertake to inform Sabaoth Care Ltd immediately if I am engaged through their introduction, including the offer of permanent employment following a temporary assignment. I agree to respect the confidentiality of service users and any other information I may have access to, at all times. I am clear that Sabaoth Care Ltd cannot guarantee assignments and that they have no responsibility to pay for hours not worked no matter the situation. I have read, understood and agree to the conditions of work for temporary workers, of which I have been given a copy.

Signed and Dated

Induction

I am aware that more detailed information on the Staff Handbook and Policy and procedures can be obtained directly from Sabaoth Care Pvt Ltd office.

Signed and Dated

Working Time Regulations

I am aware of The Working Time Regulations, 1998, and understand their implications with reference to my Terms & Conditions of Employment. Sabaoth Care Pvt Ltd time-keeping Records will confirm my hours worked on a weekly basis. Where these records confirm that I have worked in excess of 48 hours per week I agree that this 48-hour week limit under The Working Time Regulations, 1998, shall not apply to me. I understand that I may agree to opt back into the 48 -hour week limit at any time, giving the appropriate two months notice.

Signed and Dated

Data Protection *

I agree that Sabaoth Care Pvt Ltd retains the right to hold this application and any other data required to process it and to pass on to any authorized third party the details held within, also to retain these details for as long as reasonably necessary in accordance with the Data Protection Act 1988.

Signed and Dated

Application Form -Sabaoth Care Pvt Ltd

Verification