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Recruitment

MERLINE HEALTHCARE

HQ Pudsey, Radley House

Tel: 07888870448 | Email: info@merlinehealthcare.co.uk | Website: www.merlinehealthcare.co.uk

JOB APPLICATION FORM

CQC and Home Office compliant recruitment record - employee completion form

Vacancy Title (Post applied for): *

Please tell us how you heard about this vacancy:

1. Personal details

Title: *

Last Name: *

First Name: *

Address: *

Postcode: *

Home Telephone No.:

Daytime Contact No.: *

E-mail address: *

National Insurance No.: *

Date of Birth: *

Additional Information

2. Next of Kin to be notified in case of emergency

Last Name:

First Name:

Address:

Postcode:

Home Telephone No.:

Daytime Contact No.:

Relationship to you:

3. Preferred hours

We like our workers to be willing to work flexibly across the week and need to know when other commitments mean you could not be available to work: Please tick which days you prefer to work:

	Mon	Tues	Weds	Thurs	Fri	Sat	Sun
Days
Nights

4. Education/Qualifications

Please provide education, qualifications and professional development relevant to the post.

High School

College/University

Ongoing Professional Development

Training and Development

Please use the space below to give details of any training or non-qualification based development which is relevant to the post and supports your application.

Current Membership of any Professional Body/Organisation - Please give details:

5. Employment History

Please include any previous experience (paid or unpaid), starting with the most recent first.

Current or most recent employer

Name of Employer:

Position Held:

Address:

Postcode:

Date Started:

Leaving Date:

Reason for Leaving:

Contact Name of Line Manager for reference:

Brief description of duties:

Previous employer 1

Name of Employer:

Position Held:

Address:

Postcode:

Date Started:

Leaving Date:

Reason for Leaving:

Contact Name of Line Manager for reference:

Brief description of duties:

Previous employer 2

Name of Employer:

Position Held:

Address:

Postcode:

Date Started:

Leaving Date:

Reason for Leaving:

Contact Name of Line Manager for reference:

Brief description of duties:

6. Employment Gap

Please provide details for any gaps in your employment or education history lasting one month or more.

Gap Start Date	Gap End Date	Duration	Reason for Gap

7. Convictions / Disqualifications

To ensure the safety of our clients an Enhanced DBS (formerly CRB) check must be completed for all positions.

A criminal record will not necessarily be a bar to obtaining a position with Merline Healthcare Services. 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.

Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986
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.

Have you at any time received or had pending, a court conviction in the UK or overseas?

Yes

Are you aware of any Police enquiries undertaken following allegations made against you, in the UK or Overseas?

Yes

Are you subject to any fitness to practice conditions or have you been suspended or dismissed from any job?

Yes

If appointed when could you start? Give period of notice if applicable:

8. References

Please give the detail of two references. We will take up professional references once you have been interviewed and provisionally offered a post. Please make sure that you have given the full contact details of your referees so that this does not delay processing reference requests.
If you have no employer references, we will take up references with named individuals at colleges where you have studied, or people who know you in a professional capacity. Please do not put down family members or people you live with as referees.

Referee 1

Name of Referee and relationship to you:

Address:

Postcode:

Email:

Tel:

Referee 2

Name of Referee and relationship to you:

Address:

Postcode:

Email:

Tel:

9. Bank Details

Will you be working as Pay As You Earn (PAYE), or paid through a Limited or Umbrella Company?

Please give the details of your Ltd or Umbrella Company provider (if applicable). Ltd Company workers will need to provide copies of certificate of incorporation and VAT registration certificate.

PAYE

Ltd Company

Umbrella Company

Name of Bank:

Name of Account Holder:

Address of Bank:

Post Code:

Account Number:

Sort Code:

P45 enclosed?

Yes

P46 requested?

Yes

10. Working Time Regulations

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 Merline Healthcare Services Personnel that this limit should not apply.

Merline Healthcare wishes to have an agreement with you, which will apply until terminated by notice:

The average 48 hour work limit will not apply to you.
This agreement may be terminated by yourself by giving Merline Healthcare Services 4 weeks written notice.

If you accept this proposal please tick the box below. This section of the application form will then be a record of this agreement between you and Merline Healthcare Services.

I accept the 48-hour limit opt-out agreement.

11. Declaration

Statement to be Signed by the Applicant

Please complete the following declaration and tick the box below. If this declaration is not completed, your application will not be considered.

I agree that Merline Healthcare Services can create and maintain computer and paper records of my personal data and that this will be processed and stored in accordance with UK GDPR and the Data Protection Act 2018.

I confirm that all the information given by me on this form is correct and accurate and I understand that if any of the information I have provided is later found to be false or misleading, any offer of employment may be withdrawn or employment terminated.

I confirm the information provided is correct and I agree to the declaration above. *

Print Name: *

Date: *

Equal Employment Opportunities Monitoring Questionnaire Confidential

Merline Healthcare is an equal opportunities employer and will ensure that no job applicant or employee receives less favourable treatment... This form is not made available to those conducting the recruitment interview.

1. Sex:

2. Date of birth:

3. Marital status:

4. Disability:

It is recognised that disabled people are not only those whose disability is immediately apparent but also those whose disability is not immediately obvious (eg heart trouble, mental illness or diabetes).

Do you consider yourself as having a disability?

Yes

5. Ethnic origin:

HEALTH SELF DECLARATION FORM

PLEASE NOTE: If you falsify any information on this form, or fail to mention anything relating to your health which may later come to light, you may be liable for disciplinary action including immediate suspension.

1. Do you have any illness/impairment/disability (physical or psychological) which may affect your work, your own health, safety and welfare, or that of others?

Yes

2. Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?

Yes

3. Are you having, or waiting for treatment (including medication) or medical investigation at present?

Yes

4. Do you think you may need any adjustments or assistance to help you to do the job?

Yes

5. Do you have any of the following?

(a) A cough which has lasted for more than 3 weeks?

Yes

(b) Unexplained weight loss?

Yes

(d) Have you had tuberculosis (TB) or been in recent contact with open TB?

Yes

Nursing and Allied Professionals Only:

6. Have you ever had chickenpox/varicella?

Yes

7. Can you provide documented evidence of immunity to measles, mumps and rubella?

Yes

8. Have you had a BCG vaccination in relation to Tuberculosis?

Yes

9. Have you ever had a Hepatitis B test in the last 5 years?

Yes

Immunisation Record

Immunisation	Yes / No	Dates
Tetanus	Yes No
Diphtheria	Yes No
Poliomyelitis	Yes No
Hepatitis A	Yes No
Hepatitis B (showing titre levels > 100miu/ml)	Yes No
Rubella (German Measles)	Yes No
Varicella	Yes No
BCG (Tuberculosis vaccination)	Yes No

I declare that all of the information provided regarding my declaration of health and immunisation record is true to the best of my knowledge... *

join us

Recruitment

MERLINE HEALTHCARE

JOB APPLICATION FORM

1. Personal details

Additional Information

2. Next of Kin to be notified in case of emergency

3. Preferred hours

4. Education/Qualifications

High School

College/University

Ongoing Professional Development

Training and Development

5. Employment History

Current or most recent employer

Previous employer 1

Previous employer 2

6. Employment Gap

7. Convictions / Disqualifications

8. References

Referee 1

Referee 2

9. Bank Details

10. Working Time Regulations

11. Declaration

Statement to be Signed by the Applicant

Equal Employment Opportunities Monitoring Questionnaire Confidential

HEALTH SELF DECLARATION FORM

Nursing and Allied Professionals Only:

Immunisation Record

APPLICATION CHECKLIST

Documents

Annual Training Certificates