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Application Form

Personal Details
Education/Employment
References
Medical Questions/ Equal Rights
Declaration And Submit

Personal Details

Title

First Name

Surname

Contact Number

Alternative Contact Number

Email Address

Date Of Birth

National Insurance Number

DBS Number

Address Line 1

Address Line 2

City

Post Code

County

Please upload your CV Choose a file

Max. size: 500.0 MB

Your Bank Details

Bank Name

Sort Code

Account Number

NMC Registration Number (Nurses Only)

NMC Registration Number

Expiry Date

If you are a member of a professional body or union, please state which one?

Right to Work

Are you a British Citizen?

Are you elegible to work in the UK (Evidence will be required)

Have you been convicted of any criminal offence?

If yes please give details

Next Of Kin Details

Full Name

Your Relation?

Address Line 1

Address Line 2

City

County

Post Code

Primary Contact Number

Education History

Institution name

Date from

Date to

What were your qualifications?

Do you hold any further education?

If yes, please give details and dates.

Employment History

Company name

Company Contact Number

Company Address Line 1

Company Address Line 2

City

Post Code

Employer Name

Job Title

Salary

Your Responsibilites

Date from

Date To

Reason for leaving?

Do You hold further employment experience?

if yes, please give details and dates

Reference 1 (Current/Most recent employer)

Please give details of two referees (who should not be your relatives or friends), one of whom should be your previous or current employer. Please indicate against your present employer’s details if you DO NOT wish us to contact them prior to interview.

Full Name

Full Address

Telephone Number

Position

Relationship to applicant

Date from

Date to

Reference 2

Full Name

Full Address

Telephone Number

Position

Relationship to applicant

Date from

Date to

Medical Questions

First name

Surname

Position Applied for?

Please answer the following questions by ticking (√) the relevant box:

Please select one for each:

Do you suffer from or have you ever had diabetes?

Do you suffer from or have you ever had Epilepsy/fits?

Do you suffer from or have you ever had Repetitive strain injury?

Do you suffer from or have you ever had Back Problems?

Do you suffer from or have you ever had Asthma?

Do you suffer from or have you ever had frequent headaches?

Do you suffer from or have you ever had Fainting or dizziness?

Do you suffer from or have you ever had Rupture/Hernia?

Do you suffer from or have you ever had a mental illness, including depression or anxiety?

Do you suffer from or have you ever had hearing difficulty or loss?

Do you suffer from or have you ever had any eyesght problems not corrected through the use of spectacles or contact lenses?

Do you take any regular medication?

Equal Opportunities

Healing Hands Care Ltd is an Equal Opportunities employer and does not discriminate based on race, gender, disability or sexual orientation. In order to help us to monitor our recruitment in line with these values, please respond to the questions below.

Post Applied for:

Gender

Declaration

Please bring the following applicable documents to interview:   > Proof of Eligibility to work:   > UK Citizen: Passport or full birth certificate with National Insurance Card   > Non UK Citizen: Passport or full birth certificate and National Insurance card and Visa/work permit documentation   > Name Change Document: if Surname has changed since birth i.e. Marriage Certificate/Deed Poll   Photo ID: · Passport · Full Driving Licence (including the Counter Part)  Proof of Address: · You will need 2 proof of address that must be within the last 3 months, which can include utility bills, Bank Statement, Council Tax statement etc.  DBS (Formerly CRB) Details: · A current DBS must be dated within the last year.  Qualifications/training certificates  Passport size photo.

Limited Company Registered in England and Wales, Professional Healthcare Staffing
Company Reg No: 16798432

Get in Touch with us

Address: Brooklands Court, Carr Moor side, Leeds, England, LS11 5HL
24hrs Oncall Line : +44 33 0133 0060
Office Line : 0113 322 4566
Out Of Hours : +44 (0) 745 9639 263
Enquiries Contact : info@phstaffingplus.co.uk
Training Contact :training@phstaffingplus.co.uk

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