Care Application Form

Personal Details

Department

ApplicantName(Required)

First Middle Last

Verified by Passport/ID

Full Name at Birth

First Middle Last

Consultant Name

Date of Birth(Required)

Marital Status(Required)

Single

Married

Divorced

Widowed

National Insurance Number(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone(Required)

Applicant Email Address(Required)

Do you hold a driving license valid for use within the UK?(Required)

Yes

Are you willing to travel?(Required)

Yes

What form of transport do you have?(Required)

What hours would you be available to work?(Required)

I confirm that Total Assist Group have my permission to request and obtain copies of payslips from my employer/ umbrella company/ personal service company and have my permission to make this available to third parties(Required)

I agree

I confirm that Total Assist Group have my permission to generate and complete my share code check for my right to work(Required)

I agree

I agree for Total Assist to complete checks on my professional registration licence where required.(Required)

I agree

I agree that I will maintain my Right to Work status and inform Total Assist should this change at any stage of my registration.(Required)

I agree

I agree that I will adhere to the restrictions of my Right to Work status where applicable.(Required)

I agree

I agree to inform Total Assist should I be subject to any investigation or Fitness to Practice whilst registered.(Required)

I agree

Next of Kin

Full Name(Required)

First Last

Relationship(Required)

Contact Number(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Nationality

Do you hold a British or Irish Passport?(Required)

Yes

Evidence of all passports and visas are required. Please enclose photocopies with this application form and make sure you bring the originals to your interview. To work in the NHS you will be expected to communicate proficiently in English and this will be assessed at your interview

Are you an EU Citizen?(Required)

Yes

Passport Number

Share Code for online Right to Work Check:

Passport Expiry Date

I confirm that I have received and read the Key Information Document(Required)

Yes

Do you hold any of the following?

Working Holiday Visa(Required)

Yes

Working Holiday Visa Expiry Date(Required)

UK Residency Visa(Required)

Yes

UK Residency Visa Expiry Date(Required)

Student Visa(Required)

Yes

Student Visa Expiry Date(Required)

Working Permit

Yes

Working Permit Expiry Date(Required)

Should you hold any other Visa or residency permit, please provide the information below:

Signature(Required)

Declarations

In line with the Government legislation under the terms of the “Working Time Regulations” we recommend that your working hours should not exceed 48 hours per week (averaged over a 17 week period.)

Should you wish to waive this right, please confirm my ticking below:(Required)

I agree

Consent(Required)

I understand that information give on this form will be stored and handled by Total Assist Healthcare Group in accordance with the Data Protection Act 1988, however, I agree that this information may be made available for audit by the relevant Government organisations e.g. CCS / CPP Framework.

Data Protection Act 1998 / The General Data Protection Regulations 2018

In relation to the Data Protection Act 1998 / The General Data Protection Regulations 2018, you agree to the processing of personal data for the purposes of the recruitment process as well as for future potential employment arrangements for the purposes of calculating your remuneration and maintaining records on attendance, health, discipline and grievances such as are necessary for the performance of your contract. Our full GDPR Privacy Notice can be found on our website www.totalassist.co.uk/gdpr. For further information, please see the Information Commissioner's website ww.dataprotection.gov.uk, from which the above guidance is reproduced.

I acknowledge that I have been given a copy of the terms and conditions of service issued by Total Assist Healthcare Group, which is mine to keep and further more that I have read those terms and conditions and agree to abide by them. I am not aware of any condition, medical or otherwise which would affect or limit my employment or performance, other than those declared in my Pre-employment Health Questionnaire From and I am fit for work.

I authorise Total Assist Healthcare Group to disclose any convictions to any potential employers in accordance with the DBS Code of Practice and the Rehabilitation of Offenders. I declare that the details given by me on this application form are correct to the best of my knowledge and belief. I understand that if I have given any information which is false, or I withhold any relevant information, this may lead to my application being rejected, or if already appointed, to my dismissal, as well as a claim for recovery of any payments I have received, together with a claim for loss of profit to Total Assist Healthcare Group.

I also give Total Assist Group Permission to apply and to check my DBS certificate on the UK DBS update service annually.

I give Total Assist Group Permission if required to conduct any relevant right to work checks Via the Government websites.

I agree to the above.(Required)

I confirm that I have sent my most recent CV to my recruitment consultant prior to me completing this application form(Required)

I confirm

I confirm that Total Assist Group have my permission to forward my CV and personal data (for e.g. occupational health details, DBS check) for vacancies that satisfy my requirements as stated above and I give permission to check my DBS online service annually.(Required)

I agree

Employment History

Can you please provide details in the boxes below of your last 3 years employment (most recent first). If there are any gaps of 3 month or more it is important that you explain the reason why in the box below.

Employer name (1)

Position Held

Location

Date from

Date to

Employer name (2)

Position Held

Location

Date from

Date to

Employer name (3)

Position Held

Location

Date from

Date to

Employment Reference

You are required to supply at least two employment references. The 2 referees provided must cover at least 3 years employment (current/most recent). Please provide details for the manager/supervisor for each reference.

Name of first reference

First Last

Company Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Company Name

Company Email address

Company Phone Number

Referee: Job Title/Position

Date from

Date to

Name of second reference

First Last

Company Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Company Name

Company Email address

Company Phone Number

Referee: Job Title/Position

Date from

Date to

Signature to apply for references. Please sign to allow us to contact your referees.(Required)

Are you currently undergoing any disciplinary action, complaints or investigation by an NHS Trust or your professional body?(Required)

Yes

It yes, please give us more information:(Required)

Have you previously been subject to any disciplinary action, investigation or complaints by patients, relatives, other members of staff or by an NHS Trust, previous employer or professional body?(Required)

Yes

It yes, please give us more information:(Required)

I give Total Assist Recruitment permission to forward my CV to agreed clients for the purpose of obtaining employment. *(Required)

I agree

Equal Opportunities Policy

As an Equal Opportunities employer the organisation welcomes applications from suitably qualified persons from all sections of the community. The organisation is committed to achieving a working environment which provides equality of opportunity and freedom from discrimination on the grounds of race, nationality, religion, gender, class, family responsibilities, marital status, sexual orientation, age, disability or special need.
The Directors believe in best practice in Equal Opportunities on the grounds of morality, good business practice and awareness that certain kinds of discrimination are unlawful. This is a key employment value to which all employees and candidates are expected to give their support.
To ensure that the policy is effective it is essential that detailed monitoring is carried out, which necessitates the collection of information. The information on this form will be kept confidential and will not be used by those involved in the selection procedure and is for statistical purposes only and will not form part of any job application.

Ethnicity(Required)

Criminal Record Declaration

Under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, applicants for locum medical posts are not entitled to withhold information about convictions which for other purpose are ‘spent’. Therefore you are to inform Total Assist Healthcare Group in writing of any convictions for criminal offences past in the future.(Required)

Yes

If Yes, please provide details

Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ?(Required)

Yes

If you haven’t completed a DBS (previously DBS) check through Total Assist Recruitment Ltd, or if the last one was completed over 12 months ago, you are required to complete the attached DBS form provided so that we may undertake an Enhanced DBS check on your behalf. You will not be place in employment without having completed a current DBS check. Please ensure you enclose all original documentation (e.g. passport) as photocopies will not be accepted and your form will be returned to you.

Disclosure Number

Date of disclosure

Applicants Signature(Required)

Application Date

Contact us

If you have any issues with your application or just want to ask us a question, then please feel free to contact us on:
01708 388 010 or socialcareteam@totalassist.co.uk

Name

First Last

Personal Details

Next of Kin

Nationality

Confidentiality

Declarations

Employment History

Employment Reference

Equal Opportunities Policy

Criminal Record Declaration

Contact us

If you have any issues with your application or just want to ask us a question, then please feel free to contact us on: 01708 388 010 or socialcareteam@totalassist.co.uk

If you have any issues with your application or just want to ask us a question, then please feel free to contact us on:
01708 388 010 or socialcareteam@totalassist.co.uk