Position You Are Applying For

    Personal Details

    Title: MrMrsMsMissOther
    (*if less than 5 years provide further home address details dates below)

    Have you been known by any other name, from the age of 10? (*includes maiden surname) YesNo

    Used until:

    Emergency Contact Details

    Title: MrMrsMsMissOther


    ELIGIBILITY TO WORK IN THE UK

    (Please check the relevant box)
    Eligible to work in the UK and do not require a work permitCurrently in possession of a UK work permitRequired to obtain a work permit to work in the UKOther (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 YesNo
    Does your Enhanced DBS Disclosure contain any cautions or convictions? If yes, please provide details YesNo
    Have you had any disciplinary action taken against you? If yes, please provide details YesNo
    Do you consent to Proactive Medicare requesting an enhanced DBS Check, police check and any similar references on your behalf? YesNo

    PROFESSIONAL SUITABILITY

    Have you ever been subject to proceedings of medical negligence or professional misconduct? If yes, please provide details YesNo
    Have you ever been dismissed or suspended? If yes, please provide details YesNo
    Have you ever had any disciplinary action taken against you? If yes, please provide details YesNo

    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.
    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

    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.
    CommunityHospitalPrisonResidentialNursing Home

    YOUR DECLARATIONS

    Please ensure that all declarations are ticked.
    DATA PROTECTION
    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 weekI consent to work more than 48 hours per week
    TERMS AND CONDITIONS
    CONSENT TO AUDIT VERIFICATION

    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? YesNo