Phone:
07868102532
Email:
info@marielle24-7healthcareservices.com
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APPLICATION FORM FOR CARER/SUPPORT WORKER
APPLICATION FORM FOR NURSE
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APPLICATION FORM FOR NURSE
STRICTLY CONFIDENTIAL Application for Employment
Please type or complete this form in black ink
POSITION APPLIED FOR
Date of Application
Surname
First Name
Previous Name
Home Telephone No.
Mobile No.
Date of Birth
E-Mail
National Insurance No.
Current Driving Licence?
YES
NO
๐ก๐๐ซ๐ง ๐ข๐ ๐๐๐ก
Surname
First Name
Address
Relationship
Home Telephone No.
๐ง๐ฅ๐๐๐ก๐๐ก๐ & ๐ค๐จ๐๐๐๐๐๐๐๐ง๐๐ข๐ก๐ฆ
Please enclose, with your application a copy of your registration and membership card
NMC Number
RCN Number
Band
HPC Number
Do you have any Certificates in Care?
YES
NO
If yes, please attach
๐๐๐ฆ ๐ฆ๐ง๐๐ง๐จ๐ฆ
Please send a copy of your most recent DBS Disclosure (formally known as CRB)
Current DBS Disclosure (formally known as CRB)
YES
NO
HPC Number
Disclosure Number
All applications who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost. Marielle 24-7 Healthcare Services will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate.
๐ช๐ข๐ฅ๐๐๐ก๐ ๐ง๐๐ ๐ ๐ฅ๐๐๐จ๐๐๐ง๐๐ข๐ก๐ฆ For the purposes of the Working Time Regulations 1998 (as amended) I, consent to work in excess of an average of 48 hours per week, averaged over 17 weeks. I understand that I may withdraw this consent by giving Marielle 24-7 Healthcare Services not less than three monthsโ notice at any time.
In addition, I also consent to work in excess of the maximum number of hours permitted to work at night under the directive. Please note you are under no obligation to sign either declaration.
๐ฃ๐ฅ๐๐ฉ๐๐ข๐จ๐ฆ ๐๐ ๐ฃ๐๐ข๐ฌ๐ ๐๐ก๐ง
A full employment history must be detailed beginning with your current employment and covering all reasons for gaps in any given year.
From - To
๐๐บ๐ฝ๐น๐ผ๐๐ฒ๐ฟ๐ ๐ก๐ฎ๐บ๐ฒ (most recent)
๐ฃ๐ผ๐๐ถ๐๐ถ๐ผ๐ป ๐๐ฒ๐น๐ฑ
๐ฆ๐ฎ๐น๐ฎ๐ฟ๐ & ๐๐ฒ๐ป๐ฒ๐ณ๐ถ๐๐
๐ฅ๐ฒ๐ฎ๐๐ผ๐ป ๐ณ๐ผ๐ฟ ๐๐ฒ๐ฎ๐๐ถ๐ป๐ด
From - To
๐๐บ๐ฝ๐น๐ผ๐๐ฒ๐ฟ๐ ๐ก๐ฎ๐บ๐ฒ (most recent)
๐ฃ๐ผ๐๐ถ๐๐ถ๐ผ๐ป ๐๐ฒ๐น๐ฑ
๐ฆ๐ฎ๐น๐ฎ๐ฟ๐ & ๐๐ฒ๐ป๐ฒ๐ณ๐ถ๐๐
๐ฅ๐ฒ๐ฎ๐๐ผ๐ป ๐ณ๐ผ๐ฟ ๐๐ฒ๐ฎ๐๐ถ๐ป๐ด
From - To
๐๐บ๐ฝ๐น๐ผ๐๐ฒ๐ฟ๐ ๐ก๐ฎ๐บ๐ฒ (most recent)
๐ฃ๐ผ๐๐ถ๐๐ถ๐ผ๐ป ๐๐ฒ๐น๐ฑ
๐ฆ๐ฎ๐น๐ฎ๐ฟ๐ & ๐๐ฒ๐ป๐ฒ๐ณ๐ถ๐๐
๐ฅ๐ฒ๐ฎ๐๐ผ๐ป ๐ณ๐ผ๐ฟ ๐๐ฒ๐ฎ๐๐ถ๐ป๐ด
๐๐๐จ๐๐๐ง๐๐ข๐ก
(๐ถ๐๐๐๐๐๐๐ ๐ ๐๐๐๐๐๐๐๐ ๐๐ ๐๐๐๐๐ ๐๐ ๐๐๐๐๐๐๐๐๐๐๐๐๐ ๐๐๐๐ ๐๐ ๐๐๐๐๐๐๐๐ ๐๐ ๐๐๐๐๐๐๐๐๐)
Secondary School / College / University
Exams Taken
Result
Secondary School / College / University
Exams Taken
Result
Secondary School / College / University
Exams Taken
Result
Secondary School / College / University
Exams Taken
Result
๐ฅ๐๐๐๐๐๐๐๐ง๐๐ง๐๐ข๐ก ๐ข๐ ๐ข๐๐๐๐ก๐๐๐ฅ๐ฆ ๐๐๐ง ๐ญ๐ต๐ณ๐ฐ โ ๐ก๐ข๐ง๐๐๐ ๐ง๐ข ๐ข๐๐๐๐ก๐๐๐ฅ๐ฆ
Because of the nature of the work involved, the post for which you are applying is exempt from Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act (Exemption Order 1975). This means that you are not entitled to withhold information relating to any convictions you may have had.
Do you have any convictions to disclose?
YES
NO
Any information should be given on a separate sheet and sent with this application form. This information will be treated as confidential and will not necessarily preclude you from employment
๐๐๐๐๐ง๐๐ข๐ก๐๐ ๐ฃ๐๐ฅ๐ฆ๐ข๐ก๐๐ ๐๐๐ง๐๐๐๐ฆ
Outside interests, leisure time activities and other personal information which you think may assist us in evaluating your application.
๐ฅ๐๐๐๐ฅ๐๐ก๐๐๐ฆ
Please give the name and address of at least two referees, one of whom must be your present employer or your most recent employer
Name
Satus
Address & telephone Number
Name
Satus
Address & telephone Number
Name
Satus
Address & telephone Number
This organisation seeks to work in a flexible and family-friendly manner with its staff, however, unsocial hours are part and parcel of a quality care service. Weekend working is a requirement for all staff, the frequency of which will be determined at interview
๐๐๐๐๐ง๐ & ๐ฆ๐๐๐๐ง๐ฌ
Each agency worker has a responsibility at the start of their first shift to become familiar with the Clientโs general policies including, without limitation, those relating to Crash Call Procedures, the Hot Spot Mechanism for alerting security staff that an individual is in trouble, Fire Policy and the Violent Episode Policy.
๐ฌ๐ข๐จ๐ฅ ๐ฅ๐๐๐๐ฆ๐ง๐ฅ๐๐ง๐๐ข๐ก ๐๐๐๐๐๐๐๐ฆ๐ง
To complete your registration, you will be required to provide the following documentation please Tick
DBS Document
Yes
No
ID/Passport
Yes
No
Driving License
Yes
No
National Insurance Number
Yes
No
Proof of Address for 2 addresses
Yes
No
Healthcare Qualifications/Certificates
Yes
No
Acceptance
Thank you for completing this application form. I declare that to the best of my knowledge, all of the information contained and documented herein is complete and truthful.
Send
