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Proactive Medicare
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application form
application form
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Position You Are Applying For
--please select--
Care Assistant
Support Worker
Senior Support Worker
Senior Care Assistant
Personal Details
Title:
Mr
Mrs
Ms
Miss
Other
Address
Start date
(*if less than 5 years provide further home address details dates below)
Address
Start date
End date
-
+
Have you been known by any other name, from the age of 10? (*includes maiden surname)
Yes
No
Used until:
Date of birth
Emergency Contact Details
Title:
Mr
Mrs
Ms
Miss
Other
ELIGIBILITY TO WORK IN THE UK
(Please check the relevant box)
Eligible to work in the UK and do not require a work permit
Currently in possession of a UK work permit
Required to obtain a work permit to work in the UK
Other (please specify)
REHABILITATION OF OFFENDERS ACT
Due to the nature of the work that you perform, section 4(2) of the Rehabilitation of Offenders Act (1974) (Exceptions) and other statutes apply. Applicants are therefore required to provide details of convictions which are “spent” for other purposes. Any information provided will be treated as confidential and will only be considered in respect of the positions that you are applying.
Do you have a current Enhanced DBS Disclosure Document? If yes, please provide a copy
Yes
No
Does your Enhanced DBS Disclosure contain any cautions or convictions? If yes, please provide details
Yes
No
Have you had any disciplinary action taken against you? If yes, please provide details
Yes
No
Do you consent to Proactive Medicare requesting an enhanced DBS Check, police check and any similar references on your behalf?
Yes
No
PROFESSIONAL SUITABILITY
Have you ever been subject to proceedings of medical negligence or professional misconduct? If yes, please provide details
Yes
No
Have you ever been dismissed or suspended? If yes, please provide details
Yes
No
Have you ever had any disciplinary action taken against you? If yes, please provide details
Yes
No
TERTIARY EDUCATION
Include all relevant qualifications. Please also include any subjects that you are currently studying.
YOUR EMPLOYMENT HISTORY
Please provide details of your FULL employment history. All gaps over 3 months must be explained.
Include the month and the year, starting with your most recent or last job.
Date from:
Date to:
Date from:
Date to:
Date from:
Date to:
Alternatively please upload your CV Here:
>
YOUR EMPLOYMENT REFERENCES
Please provide the full name and work address of two professional referees. These should be your current / most recent employer and they must be able to comment on your ability to do the job you are applying for. Your referees must be a senior grade to yourself and you must have worked for the person for a period of more than three months
Referee #1
Referee #2
CHECK TO INDICATE YOUR CONSENT FOR YOUR REFEREES TO BE CONTACTED
TRAINING COMPLETED
Please tell us about any other qualifications/training you have, such as NVQ/QCF’s, First Aid, Manual Handling or Food Safety.
EXPERTISE AND EXPERIENCE
Please tick which facilities that you have worked in and your expertise. This will enable us to best match you with the appropriate job placement.
Community
Hospital
Prison
Residential
Nursing Home
YOUR DECLARATIONS
Please ensure that all declarations are ticked.
DATA PROTECTION
I agree that Proactive Medicare retains the right to hold this application and any other data associated to process it and pass on to any authorized third party the details held within, also to retain the details for as long as reasonably necessary in accordance with the Data Protection Act.
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.
I do NOT consent to work more than 48 hours per week
I consent to work more than 48 hours per week
TERMS AND CONDITIONS
I hereby confirm that the information given is true and correct. I consent to my personal data and employment/educational history being forwarded to clients. I understand that should the information I have given be untrue I accept full responsibility for any consequences this may bring. I consent to references being passed onto potential employers. If, during the course of a temporary assignment, the client wishes to employ me direct, I acknowledge that the agency will be entitled either to charge the client an introduction/transfer fee, or agree to an extension of the hiring period with the client (after which I may be employed by the Client without further charge being applicable to the Client). We may check the information collected, with third parties or with other information held by us. We may also use or pass to certain third parties’ information to prevent or detect crime, to protect public funds, or in other way permitted or required by law.
CONSENT TO AUDIT VERIFICATION
In line with the nature of the work I will be undertaking, I understand that the confidential documentation I have given in line with compliance procedures may be audited in relation to the provision of the services at any time and I consent to this.
PENSION
In line with government legislation, Proactive Medicare offer a pension scheme with NEST. All workers are enrolled onto our pension scheme, of which full details will be sent to you.
If you wish to opt out of NEST pension scheme, you may do so by indicating bellow, or alternatively, you can opt out upon being employed by Proactive Medicare.
Do you want to opt out of the Proactive Medicare pension scheme with NEST?
Yes
No
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