Application Form

Date Registered *//

Name *

First

Last

Post applied for *

Nationality *

D.O.B *//

Upload passport sized photo *

Click or drag a file to this area to upload.

NI Number *

Telephone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Time at address (from) *

Please provide addresses to cover min 5 years – on separate sheet if necessary

Time at address (to) *

Please provide addresses to cover min 5 years – on separate sheet if necessary

Preferred areas of work *

How did you hear about Team Support? *

How many hours per week are you able to work? *

Select availability *

DAYS
NIGHTS

NEXT OF KIN

Name *

First

Last

Phone

Relationship *

RELEVANT TRAINING TO JOB ROLE

Qualification / Course *

DATE FROM *//

DATE TO *//

Awarding body *

WORK HISTORY

FULL employment history required (month/year required). Please include agency work (if any). All employment gaps MUST be explained (i.e.: unemployed, travelling, maternity, study, etc.)

From *//

To *//

Name and Address of Current Employer *

Job title *

Reason for leaving *

Previous Employment 2

From//

To//

Name and Address of Employer

Job title

Reason for leaving

Previous Employment 3

From//

To//

Job title

Name and Address of Employer

Reason for leaving

If your employment history goes back 4 – 10 years, please briefly specify below the name, your job title, and the period of employment.

Please provide details of your current and/or previous agency work (if applicable). Please specify the names of the agencies and the period/dates of employment.

ELIGIBILITY TO WORK IN THE UK

Eligibility to work in UK - UK RESIDENT (British Passport) *

UK Resident (British Passport)
Visa / Biometric Resident Permit (BRP) card

Type of Visa

Others (please specify)

Passport Number

Visa Expiry

REGISTERED BODY DETAILS (if applicable to job role)

NMC PIN number or HCPC Number

Expires

Are you a member of a recognised union?

YES
NO

If yes please list below:

Please confirm date of last Appraisal //

Completed with

Please confirm date of last revalidation

Confirmed by

To be completed by all applicants

Are you, or have you ever been suspended from working at any place of work, or are you currently under investigation for any reason? *

YES
NO

Please provide details (on separate sheet if necessary)

REFERENCES

Please supply details of a minimum of 2 professional people of senior position to yourself, at least 1 being from your current or most recent employment. They must be able to comment on your ability to undertake the duties of the position applied for. Students may provide details of course tutor. In all cases, Clinical staff should provide referees who have supervised and can give a clinical reference. Referees cannot include relatives or friends Home addresses and personal contact details of referees cannot be accepted. All references must cover your past 3 years of employment.

REFERENCE 1

Name *

First

Last

Job title

Organisation *

Relationship to applicant *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Email *

REFERENCE 2

Name *

First

Last

Job title *

Organisation *

Relationship to applicant *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Email *

REFERENCE 3

Name

First

Last

Job title

Organisation

Relationship to applicant

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Email

DATA PROTECTION ACT 1998 AND INSPECTION

I hereby consent to information relating to me being processed by the Company (Team Support Healthcare Ltd) in order that it may properly carry out its duties, rights and obligations. I understand that such processing will principally be for personnel, administrative and payroll purposes. I also understand that the term ‘processing’ includes the obtaining, recording or holding of information or data carrying out any operation or set of operations on the information data, including organising, altering, retrieving, consulting, using, disclosing, combining, or destroying the information data. From time to time the Company is audited by outside contracted clients and Agencies (i.e. NHS/CQC) that requires your consent. I consent to outside clients and outside agencies having access to information held on my personal file for inspection purposes. For the purpose of recruitment decisions some or all of the information contained in this application form may be shared with clients for the purpose of finding suitable placement. I agree for the Company to perform a DBS Check on an ongoing basis, and for the Company to obtain a copy of my DBS Certificate for their records. Should I wish to withdraw my consent for the Company to perform a check, I shall give the Company written notice of such withdrawal. I hereby agree to all of the above

Signature *

Name *

First

Last

Date *//

WORKING TIME REGULATIONS

(Please tick as appropriate)

Agree that I may work more than the average of 48 hours a week.
Will not work more than the average of 48 hours a week.

Signed *

If I change my mind, I will give Team Support Healthcare one month’s notice in writing.

Date *//

REHABILITATION OF OFFENDERS ACT 1974

Team Support Healthcare complies fully with the Disclosure and Barring Service (DBS) code of practice and we undertake to treat all applicants for positions fairly. Please note that having a criminal record will not necessarily bar you from working for us. However, non-disclosure at this time may affect your application with us.

The work for which you are applying is exempt from the Rehabilitation of Offenders Act 1974, because it involves substantial opportunity for access to children and vulnerable adults. You are therefore required to declare details of any spent, unspent convictions, cautions, reprimands, or warnings you may have save where the spent conviction or caution is protected under the Exceptions Order 1975 (2013).

The information you give will be regarded as confidential and will only be disclosed in relation to healthcare appointments. The amendments to the Exceptions Order 1975 (2013) provide that 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 filtering of these cautions and convictions can be found on the Disclosure and Barring Service website.Team Support Healthcare will arrange for a check to be made with the police for the existence and content of any criminal record in your name. Any information received from the police will be kept in strict confidence and will be destroyed immediately after the selection process in complete. The disclosure of a criminal record, or other information, will not debar you from appointment unless Team Support Healthcare considers, or is advised, that it renders you unsuitable for appointment. In making this decision Team Support Healthcare and the authority will consider the nature of the offence, how long ago and what age you were when it was committed and any other factors, which may be relevant.

Failure to declare any spent, unspent convictions, cautions, reprimands, or warnings which are not protected may well disqualify you from appointment, or result in your appointment being terminated when the discrepancy comes to light.

I agree for Team Support Healthcare to perform a DBS Check on an ongoing basis (as per relevant policies and procedures) and for Team Support Healthcare to obtain a copy of my DBS Certificate for their records and any managed service or client records. Should I wish to withdraw my consent for Team Support Healthcare to perform a check, I shall give written notice of such withdrawal.

Do you have any spent, unspent convictions, cautions, reprimands or warnings? *

YES
NO

Are you currently under investigation for a criminal act? *

YES
NO

If YES to either of the above, please give full details below

PAYROLL BANK DETAILS

Bank / Building Society Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of account

Account Number

Sort Code

Date *//

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

I hereby give my consent to the Company to process the following information below:

Personal data · Name · Date of birth · Contact details, including telephone number, email address and postal address · Experience, training and qualifications · CV · National insurance number · Referencing · Bank Details

Sensitive personal data · Disability/health condition relevant to the role · Criminal conviction · Ethnic Origin

I consent to the Company processing the above personal data for the following purposes:.

• For the Company to provide me with work-finding services.

• For the Company to process with or transfer my personal data to their clients in order to provide me with work-finding services.

• For the Company to process my data on a computerised database namely Eclipse Software, in order to provide me with work-finding services. • For the Company to process my data using automated decision making processes

• Right to Work and identity checks

• Referencing

• Diversity Monitoring

• Fraud &Crime Prevention

• For the company to complete Training Record checks

• For the company to complete Occupational Health Checks, and Qualification Checks.

• For the company to do online checks for DBS update service, NMC pins and HCPCs.

• For the company to retain DBS on file

I also consent to the Company processing my personal data with third parties for the purposes of internal audits and investigations carried out on the Company to ensure that the Company is complying with all relevant laws and obligations.

I am aware that I have the right to withdraw my consent at any time by informing the Company that I wish to do so.

Sign here *

DECLARATION: The information that I have given in this registration form is, to the best of my knowledge, complete and accurate in all respects. I understand that knowingly giving false information will disqualify me from registration with the Company. I also agree to keep the Company advised of any changes to any of the information supplied. I am aware that where I have provided false information or provide false update information in the future the Company reserves the right o report this to my professional body if appropriate.

Date / Time//