United Kingdom 0113 360 6571 info@easycareltd.co.uk

Application Form

EASYCARE Suppliers UK Limited request you fill out this form honestly and accurately, as it is then used in the recruitment process to assess your suitability for temporary assignments.

Along with the completed Application Pack, we will need to sight the originals of the following documents:

• Passport and Visa (if app)
• Drivers Licence (if app)
• Proof of Address x2
• Proof of National Insurance
• CRB/DBS Disclosure Certificate
• Mandatory Training Certificates (Skills for Health Aligned)
• Qualification Certificates (NVQ in Health & Social care/ NMC Statement of Entry/ HCPC Certificate and Card/ GMC
Certificate)
• Immunisations – (Hep B, Rubella, Measles, Varicella, BCG Scar and TB (HIV, HEP B Antigen and HEP C if EPP)


48 Hour Waiver Agency Worker Handbook Declaration Confidentiality Agreement Healthcare Declaration




Source


Availability?




Personal Details

Have you ever been known by any other name?



Do you hold a valid UK Drivers Licence?




Next of Kin Details


Right to Work


Training and Qualifications

Medical Indemnity Insurance – Nurse/Midwife Only


Previous Employment- Full Work History


References

Please provide us with your referee details. Your referees must be either a Manager or Supervisor and be of a clinical state.


Health and Disability

The following questions on health and disability are asked in order to find out your needs in terms of reasonable adjustments to access our recruitment service and to find out your needs in order to perform the job/position sought.

Do you have any health issues or a disability which may make it difficult for you to carry out functions which are essential for the role you seek?




Health Assessment Questionnaire

Have you had any medical problem in the past that has prevented you from working at night?


Are you diabetic?


Do you have angina, or other heart problems that may affect your fitness?


Have you had duodenal or stomach ulcers in the past, or are you under treatment for those at present?


Have you had any continuing bowel problem, for instance following major surgery?


Do you have any chronic chest problem such as asthma, emphysema or bronchiectasis?


Do you have any disability affecting mobility that will cause difficulties in arranging night work?


Do you have any recurrent or continuing sleep disturbance requiring medical advice?


Are you having specialist care requiring your attendance at hospital clinics for treatment?


Do you have any other health problem that affects your fitness for night work?


Are you taking any medication to a strict timetable?



Data Protection Act 1984 & 1998

The Data Protection Act 1998 requires that any staff handling personal data must follow certain principles in relation to the data that they hold. Individuals have rights of access to data that is held and rights to claim for damages if various offences occur. This covers manual as well as computerised records.

In implementing the legislation, at EASYCARE Suppliers UK Limitedwe adopt a simple and straightforward policy.

If you are unsuccessful in this application, we will keep this form on file for 6 months should you wish to be considered for other vacancies.



Criminal Record Check/ ISA Declaration

I have completed an application for a criminal record check and can further state that to the best of my knowledge and belief, there will not be any positive disclosure made that will preclude me from working with vulnerable adults or children.

I also give permission for a copy of the disclosure to which I am subject, being made available to a named authorised person upon written request, who acts on behalf of a National Government or Local Government Department for auditing purposes.


Working with Us

It is our policy to employ the best qualified personnel and provide equal opportunity for the advancement of employees including promotion and training and not to discriminate against any person because of race, colour, ethnic origin, national origin, sex, sexual orientation, religion or belief, pregnancy, trans-gender status, marital or civil partnership status, age or disability.

I authorise EASYCARE Suppliers UK Limitedto obtain references to support this application once an offer has been made and accepted. I release EASYCARE Suppliers UK Limitedand referees from any liability caused by giving and receiving information.


Employees Consent Form EasyCare Suppliers UK Limited

I confirm that my information can be shared with clients of EASYCARE Suppliers UK Limitedand can be used for the payment of duties I carried out.
I agree that I may work for more than an average of 48 hours a week. If I change my mind, I will give my employer up to 3 months’ notice in writing to end this agreement.




Declaration

I confirm that the information given on this form is, to the best of my knowledge, true and complete. Any false statement will be sufficient cause for rejection or, if employed, dismissal.




Document Uploads (Required)

48 Hour Waiver* Agency Worker Handbook Declaration * Confidentiality Agreement * Healthcare Declaration *

Passport/Right to Work * Proof of Address * Proof of National Insurance Number

CV * ID Photo (to create staff profile) *

Up to date DBS Check Certificate/DBS Reference Number * For HCA's - Mandatory Training Certificate

Registered Nurses - NMC Pin Training certificate- Administration of medicines if applicable **

Chefs - Level 1/2/3 Diploma in professional cookery or level 4 Diploma in professional Culinary Arts

Bank Details and Tax Code *

EasyCare

A leading provider of health care staffing solutions, registered as a limited company in England and Wales

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Address

Matrix Business Centre
Goodman Street
West Yorkshire
Leeds, LS10 1NZ
0113 360 6571
EasyCare Supplies UK Ltd, All rights reserved.