Application for EmploymentPlease enable JavaScript in your browser to complete this form.CONTACT DETAILS - Step 1 of 6Personal Details 1TitleName *FirstMiddleLastDate of Birth *Gender *MaleFemaleOtherGender if selected other*NMC Pin/HCPC NumberIf ApplicableNational Insurance No: *Contact DetailsMobile Number *Home PhoneEmail *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPersonal Details 2Nationality *BritishEU CitizenOtherSpecify nationalityRace / Ethnicity *White BritishWhite IrishBlack BritishAfricanCaribbeanMixedAsian BritishIndianBangladeshiPakistaniChineseOtherSpecify your ethnicityDo you have the right to work in the UK? *YesNoEmmanuel Healthcare is required to check that all applicants are legally entitled to work in the UK. In line with UKBA guidance on the prevention of illegal working we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by Standby Healthcare for temporary work. UK candidates are asked to provide a passport or full birth certificate with a P45/P60 or National Insurance card. Overseas and EEA candidates are asked to provide a passport, national identity card, travel document or official Home Office letter certificate endorse to show that the holder is allowed to stay in the UK and is allowed to do the type of work in question.Upload your CV Click or drag a file to this area to upload. Note: maximum CV size is 5 MB, upload only .doc, .docx, .pdf filesNextEXPERIENCEPOSITION APPLYING FOR *Healthcare AssistantSupport WorkerRegistered General NurseRegistered Mental Health NurseYears of experience *0123+Are you a driver with access to a vehicle? *YesNoHave you completed mandatory training within the last year?* *YesNoMandatory TrainingMoving & HandlingBasic life supportHealth and SafetyFire SafetyFirst AidInfection ControlFood Safety & NutritionMedication AdministrationSafeguarding Vulnerable Adults & ChildrenPlease tick if you have completed the following training within the last 12 monthsTraining Dates:Are you available to work? *Up to 24 Hours per weekAbove 24 Hours per weekWhich agencies are you working with at the moment? *Employment HistoryEmployerPositionDutiesDate From - ToQualificationsPlease give details of your education and qualifications obtained. This includes any qualification which you are studying for now. Name of awarding body *Examinations passed, qualifications, skills gained *Year *Grade *PreviousNextDECLARATION OF CRIMINAL RECORDHave you ever been convicted by the courts or cautioned, reprimanded or given a final warning by police?* *YesNoAre you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this work? *YesNoAre you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this work? *YesNoDo you have a disability as outlined in the Disability Discrimination Act 1995 and 2005? *YesNoPlease state the type of disability you have:In relation to any disability, do you have any particular requirements?Do you have a current DBS Disclosure? *YesNoPreviousNextMEDICAL HISTORYThe purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Any impairment that may affect your ability to work or perform duties safely? *YesNoEyesight problems not corrected by glasses/contact lenses? *YesNoDifficulties in walking, bending, lifting or any other movement? *YesNoDifficulties in hearing, not correctable by hearing aid? *YesNoMuscular-skeletal problems including arthritis or back problems? *YesNoSignificant discomfort when using a keyboard? *YesNoPsychological conditions including stress at work? *YesNoFits/blackouts or epilepsy? *YesNoSuffered any accidents that significantly affected you physically or mentally? *YesNoSuffered any accidents that significantly affected you physically or mentally? *YesNoTreated for tuberculosis? *YesNoHave you ever had chicken pox or shingles? *YesNoGastrointestinal problems including hepatitis? *YesNoTriple vaccination as a child (Diptheria / Tetanus / Whooping cough)? *YesNoCardio-vascular problems including hypertension or a blood disorder? *YesNoDysentery, typhoid, paratyphoid, food poisoning, salmonella, severe gastroenteritis or diarrhoea? *YesNoIf you are under any medication (please give name of drug and dosage) *YesNoAre you waiting for any medical treatment investigation or tests at the moment? *YesNoHave you ever suffered from any serious/ frequent headaches or episodes of migraine? *YesNoDo you think you have had any illness that was made worse by your work? *YesNoHave you ever had any drug or alcohol problems? *YesNoHave ever had any concern/fear that you may have a health problem? *YesNoCoughing/vomiting/diarrhoea/rash in the last 12 months? Have you had a cough for more than 3 months? Coughing/vomiting/diarrhoea/rash blood or any unexplained loss of weight or fever? *YesNoIf you have answered ‘yes’ to any of the above, please give details:PreviousNextREFERENCESAll candidates – please give details of two employment referees whom we may contact about your suitability for the post. One of these should be your most recent employer. Referees must not be related to you. If you are a school/college leaver, please give the name and address of a head teacher and also the manager of your most recent work experience placement – if applicable. Referee 1Name of Referee 1 *FirstLastJob Title *Organisation *Referee Email AddressReferee Contact No. *Referee 2Name of Referee 2 *FirstLastJob Title *Organisation *Referee Email AddressReferee Contact No. *PreviousNextPlease state where you saw this post advertised:Declaration I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for our appointed Occupational Health Services provider to make recommendations to my employer.Right To WorkIt is a legal requirement that before any offer of work can be made all candidates provide the company with confirmation of their eligibility to work in the UK by providing one of the original documents detailed below.A passport which describes the holder as a British Citizen or as having a right of abode in the United Kingdom or a passport or other travel document to show that the holder has IDENFINITE LEAVE TO REMAIN in the United Kingdom and is not precluded from taking the work in question.A passport or identity card issued by a State which is party to the European Union and EEA Agreement and which describes the holder as a national or a state which is a arty to that agreement.A letter issued by the Home Office or the Department of Education and Employment indicating that the person named in the letter has permission to take agency work in question or a biometric residence permit.Registration form DeclarationI declare that all information given in this registration form is to the best of my knowledge complete and accurate in all respects and that I am eligible to work in the UK.By using this form you agree with the storage and handling of your data by this website as defined in our Privacy PolicyName *FirstLastDate / TimePreviousNameSubmit