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020 3921 0167
Application Form
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*
" indicates required fields
1
2
PERSONAL DETAILS
3
PROFESSIONAL REGISTRATION DETAILS
4
QUALIFICATIONS
5
6
7
REFERENCES
8
9
DECLARATION
PERSONAL DETAILS
Title
Title
Mr
Ms
Mrs
Miss
Dr
Your Name
*
First
Middle
Last
Have you ever been known by another name?
Date of Birth
*
Day
Month
Year
Gender
*
Male
Female
Address
*
House name or no:
Street:
City
County:
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Date of Residence
*
Day
Month
Year
Tel Work:
Tel Home/Mobile:
*
Your Email Address
*
Hidden
What job/s are you applying for?
*
New Test JOB
Test Job
EMERGENCY CONTACT / NEXT OF KIN
Next of Kin Name
*
First
Last
Next of Kin Email
*
Relationship to you:
*
Tel / Mobile:
*
NATIONALITY AND ELIGIBILITY TO WORK
Do you hold a British/EU Passport?
*
Yes
No
Nationality
*
Do you hold a visa?
*
Yes
No
Please provide right to work share code if applicable
Share code:
National Insurance Number
Passport Number:
Expiry Number:
PROFESSIONAL REGISTRATION DETAILS
Are you registered with any Professional Body?
*
Yes
No
Professional Body Membership
*
NMC
GMC
Other
Please select all applicable
Other Professional Body
Registration Number:
*
Expiry Date:
*
Day
Month
Year
Revalidation Date:
*
Day
Month
Year
Band/Grade:
*
Speciality
*
PROFESSIONAL APPRAISAL
(List your most recent appraisal)
Date of Appraisal:
*
Day
Month
Year
Location of Appraisal:
*
Completed by
*
QUALIFICATIONS
Qualification:
*
Qualification:
Date Achieved: (To and from)
University/College Name:
Add
Remove
Please click the + button to add additional rows for more qualifications.
WORKING TIME DIRECTIVE
The working time regulations 1998 state that you are unable to work in excess of an average of 48 hours per week (calculated over a 17-week period) unless agreed with the Urgent Response Healthcare that this limit should not apply.
*
I agree to limit my working week to no more than 48 hours
I disagree to limit my working week to no more than 48 hours
PROFESSIONAL REFERENCES
Please note that we will need to obtain satisfactory references to complete your registration with Urgent Response Healthcare and before you are offered an assignment. Please provide contact details of referees that we may approach from each place of employment in the last 3 years.
Guide to acceptable reference contacts:
Referees must have supervised your work and be of a more senior grade/band. If we are unable to gain an appropriate reference from a supervisor, we will approach HR.
We can only accept references from a work email address.
We can only accept references from employers that current work as your previous workplace.
If you have worked for an agency, please provide their contact details as well as the client you have worked for.
If you are currently in full-time Education or have been in Education in the last two years, please provide your tutor/lecturer as a reference contact
REFERENCE 1 of 2
Organisation:
*
Your Job title:
*
Ward/Dep:
*
Grade/ Band:
*
Dates of Employment
From
Day
Month
Year
To
Day
Month
Year
Referee Name:
*
Referee Position:
*
Work Email:
*
Capacity in which known (i.e. Manager):
*
Can we contact prior to interview?
Yes
No
Referee contact number:
*
REFERENCE 2 of 2
Organisation:
Your Job title:
Ward/Dep:
Grade/ Band:
Dates of Employment
From
Day
Month
Year
To
Day
Month
Year
Referee Name:
Referee Position:
Work Email:
Capacity in which known (i.e. Manager):
Can we contact prior to interview?
Yes
No
Referee contact number:
Rehabilitation of Offenders Act 1974 (Exceptions)(Amendment) Order 1986
We would draw your attention to the following statement: - “Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act, 1974, by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986.
Applicants are, therefore, obliged to disclose information about any convictions which for other purposes would be regarded as ‘spent’ under the provisions of the Act”. Failure to disclose such convictions could result in dismissal or disciplinary action by the employing organisation. Any information given will be confidential and will be considered only in relation to any post to which the conviction applies.
DECLARATION OF CRIMINAL RECORD
To ensure the safety of our clients an enhanced DBS check must be completed for all positions. A criminal record will not necessarily be a bar to obtaining a position with Urgent Response Healthcare. If a check is returned and reveals any information, this will be discussed with the applicant. The director(s) will make a decision as to whether the offer of employment should be withdrawn.
Do you have convictions, cautions, reprimands or final warnings that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198?
*
Yes
No
Do you have any convictions, cautions, reprimands or final warnings which would not be filtered in line with current guidance?
*
Yes
No
Have you had a Police check in another country within the last 6 months? If so, please provide details below and enclose a copy if held?
*
Yes
No
Have you ever been suspended or are you currently under investigation by an NHS Trust, professional body or any other organisation?
*
Yes
No
Have you ever had an Enhanced Disclosure and Barring Service (DBS) Check? (Formerly Criminal Records Bureau check or CRB)
*
Yes
No
Disclosure no:
Date
Day
Month
Year
Company that conducted the check:
DBS Update Service Number
If you have signed up for the DBS Update Service, please provide the details of your DBS number:
DECLARATION
Agency worker handbook and Terms of engagement
Please download and print the Agency worker handbook from our website.
Download Terms of Engagement
Download Handbook
Consent
I can confirm that I received each section of the Agency worker handbook and Terms of business.
IDENTIFICATION
Please provide a selfie holding your photo ID next to your face as demonstrated below.
Acceptable Photo ID’s:
Passport
UK Driving Licence
UK Biometric Residence Permit card
HM Armed Forces Identity card
EEA government issued identity card
How to properly take a selfie while holding my ID?
The ID you're holding should be the same as the one you photographed in the steps described above;
The photo side of your ID should be facing towards the camera;
Take your selfie in a well-lit space
Make sure the info on your ID is clearly legible
Make sure your face is fully visible unobstructed by masks, hats, or glasses, etc.
Make sure your ID isn't blocking your face or blocked by your fingers.
Upload Selfie with Photo ID
Max. file size: 1 GB.
Confirmation of Face to Face
*
I can confirm that I have provided the original documents to Urgent Response Healthcare as part of the registration process.
General Data Protection Regulations (GDPR) Please view our website for the full privacy policy. The link to the website is: www.urgentresponsehealthcare.com
I can confirm that I viewed the privacy policy and I would like to continue subscribe to Urgent Response Healthcare mailing list including, communication, emails, phone calls, texts, shift availability, payment and compliance.
*
I can confirm that I viewed the privacy policy and I would like to continue subscribe to Urgent Response Healthcare mailing list including, communication, emails, phone calls, texts, shift availability, payment and compliance.
*
I can confirm that I have read this document fully and that all the information provided to Urgent Response Healthcare is correct and to the best of my knowledge. I give consent to contact referees regarding the information I have provided unless specified otherwise. I will inform Urgent Response Healthcare should anything change, that might affect my position and I understand the information given on this form will be processed by computer and used for registration purposes, under the Data Protection Act 1998.
1. I understand that if I am at any stage charged or cautioned after signing this declaration, I must inform Urgent Response Healthcare.
2. I acknowledge that I have been given a copy of the terms of engagement of service issued by Urgent Response Healthcare, which is mine to keep, and furthermore that I have read those terms of engagement and agree to abide by them.
3. 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 Occupational Health Form.
4. I acknowledge and confirm that Urgent Response Healthcare is authorised to apply for and obtain a Disclosure and Barring Service (DBS) check and references from any previous employers and educational establishments.
5. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future that Urgent Response Healthcare may cease to offer me further agency placements without notice, as well as claim for recovery of any payments I have received, together with a claim for loss of profit to Urgent Response Healthcare.
6. I agree that the maximum weekly working time specified in Regulation 4(1) and (2) of the Working Time Regulations 1998 shall not apply to working with Urgent Response Healthcare unless specified above.
7. I acknowledge that my personal details will be stored and handled correctly by Urgent Response Healthcare in accordance with the Data Protection Act 1998, however, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents - DBS, Occupational Health, References, Right to Work).
8. I give consent for Urgent Response Healthcare to disclose my documentation including my payslips and timesheets to be shared with the NHS national framework, or any person, firm or organisation duly authorised on the authority’s behalf for audit purposes only.
9. I understand that if I am on a student visa I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student change, I must inform Urgent Response Healthcare.
10. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform Urgent Response Healthcare.
11. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for Urgent Response Healthcare, I must inform Urgent Response Healthcare immediately.
12. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will inform Urgent Response Healthcare if I am under investigation or suspended by my professional regulatory body or employer at any point while working for Urgent Response Healthcare.
13. I confirm that when asked about my working history (primarily, but not exclusively, for the purpose of the Agency Workers Regulations) I will provide accurate information.
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