Registration Form – Nurses Alliance Limited

Title *MissMrsMsMr

Surname *

Forenames *

Contact Number *

Date of Birth *

Email Address *

National Insurance Number *

Address *

Postcode *

If you have an up-to-date CV and wish to wish to upload it, please do so here.

No file chosen

Qualifications

Are all your relevant qualifications listed on a CV attached to this form?

If you answered "NO" to the above question, please inform us of all your relevant qualifications below.

Academic Qualifications

Please provide us with the details of any academic qualifications you may hold:

Institute/Location of Study

Qualification

Date (to&from) MM/YY

Professional & Clinical Qualifications

Please provide us with the details of any professional/clinical qualifications you may hold:

Institute/Location of Study

Qualification

Date (to&from) MM/YY

Note: Please bring with your original certificates of all relevant qualifications and certificates you have obtained.

Current Employment Information

Name & Details of Employer: name, address, contact details *

Position Held: *

Start Date (MM/YY): *

End Date (MM/YY): *

Reason for Leaving: *

10 YEARS EMPLOYMENT HISTORY - PLEASE DETAIL BELOW

To register you as a Nurses Alliance Limited, we require a full breakdown of all jobs you have worked in the past 10 years (whether this is as a carer or in another profession. If this information isn't given in full on an attached CV (with reasons given for any gaps) we will need the information to be provided below. This will not affect the outcome of your application, however it is information we require for compliance purposes (and said information will not be shared with any third parties etc.).

Have you listed your previous 10 years of employment on a CV attached to this form?

If this information is not present on an attached CV, please fill out your 10 year employment history below:

Company Name

Position Held

Start / End Date (MM/YY)

Reason For Leaving

Please give details of the reasons for any gaps in employment (this will not affect the outcome of your application in any way): *

Community, Voluntary or Intern Experience

If this information is not present an an attached CV, please provide it below:

Company Name

Position Held

Start / End Date (MM/YY)

Reason For Leaving

Permissions to Work in the UK

Are there any restrictions on your right to work in the UK that may prevent your employment opportunity with Kare Plus? *YesNo

If your application is successful, you will be required to provide evidence that you have the right to work in the UK. Do you have a passport/VISA/birth certificate? Evidence to be provided and a copy taken. *YesNo

NMC PIN & Indemnity Insurance - Registered Nurses ONLY

NMC PIN:

Expiry Date:

Indemnity Insurance Provider:

Skills & Experience

In support of your application, please detail your relevant skills, experiences and personal qualities which you believe are relevant to the position you're applying for: *

Professional References

Please provide full names and addresses of two professional employment referees covering between 5-10 years employment history and one character referee. Your first reference must be from your current or previous place of work and addressed to your line manager. Nurses Alliance Limited cannot use friends or relatives for any employment references. Employment references cannot be sent to private or personal home addresses. You must provide workplace addresses and the referee must be a higher grade of staff than you yourself i.e. your line manager.

If this is going to cause a problem for you, we may have other options available. In certain circumstances we can accept a second character reference in lieu of a second professional reference. An example of when we would do this would if you've only worked for one company before, or you've recently moved here from abroad). Also, in cases where we are unable to obtain a reference from a previous employer (for example, if the company you prevously worked for is now defunct) we may ask for payslips from your previous place of employment - this will allow us to verify your claims.

If you believe it would be suitable to pursue either of these routes, email admin@nursesallianceltd.co.uk with all relevant information and answer N/A on any parts of the form you feel you are unable to fill in.

PROFESSIONAL REFEREE 1 [Must be UK-based]

Name *

Job Title *

How do you know this person? *

Company: *

Street Address *

Telephone Number: *

Email Address *[Note: This MUST be a professional email address; NOT a Gmail, Hotmail etc.)

PROFESSIONAL REFEREE 2 [Must be UK-based]

Name *

Job Title *

How do you know this person? *

Company: *

Street Address *

Telephone Number: *

Email Address *[Note: This MUST be a professional email address; NOT a Gmail, Hotmail etc.)

CHARACTER REFEREE [Must be UK-based]

Name *

Job Title *

How do you know this person? *

Company: *

Street Address *

Telephone Number: *

Email Address *[Note: This MUST be a professional email address; NOT a Gmail, Hotmail etc.)

Next of Kin Details

Title *MissMrsMsMr

Surname *

Forename *

Relationship: *

Contact Number: *

Address: *

Postcode: *

Do you have any criminal convictions/ cautions or bind overs in the UK or abroad? (whether related to work or not) *YesNo

If 'Yes' please detail below:

Are you / have you been under / or undergoing any clinical investigation, disciplinary or suspension process pending or otherwise? *YesNo

If 'Yes' please detail below:

HEALTH DECLARATION

By signing this form you are confirming that all given information is correct. Having any or all of the below conditions does not automatically disqualify you from registering or working as a Nurses Alliance Limited - though failing to disclose any known pre-existing health conditions may result in your application being terminated.

Do you suffer from diabetes? If "yes", give further info - is it under control, is your blood sugar stable and does it require treatment with insulin injections on a strict timetable? *NoYes

How many days and on how many occasions have you been absent from work in the last two years, and for what reason? *

Do you suffer from any heart disease/problems or circulatory disorders i.e. angina, high blood pressure etc? If "yes", what is your condition, and does it affect your physical stamina in any way? *NoYes

Do you suffer from any stomach or intestinal disorder i.e. ulcers, irritable bowel etc? If "yes" give further info. *NoYes

Do you get frequent indigestion, heartburn or belching? If "yes" please specify. *NoYes

Text

Do you have any condition where the timing of meals is particularly important? If "yes" please specify. *NoYes

Do you suffer from any medical condition affecting your sleep? If "yes" please specify. *NoYes

Do you have asthma, bronchitis or any chronic chest disorder? If "yes", please describe any problems you are having at present, and any particularly troublesome symptoms. Please also let us know when you last had an attack. *NoYes

Do you suffer from depression, anxiety or any other mental health condition? If so please give details. *NoYes

Have you ever had a drug or alcohol addiction? If so please give details. *NoYes

Please state your weekly alcohol intake: *

Please state your weekly tobacco/cigarette consumption: *

Do you have any condition requiring regular medication at strict times e.g. epilepsy? If so, please let us know which medication you require, and when you need to take it. *NoYes

Do you have any other chronic health problems/conditions? If so please state what: *NoYes

Do you have any health conditions that may affect your ability to do night work? If so please state what: *NoYes

Do you consider yourself to have a disability that may affect your ability to do your job? If so please give details: *NoYes

Do you have any other condition or health problem that the Occupational Health Unit should be made aware of, or that you would like advice about? If so please give details: *NoYes

Are you currently receiving any treatment from your G.P., Osteopath, Homeopath, Chiropractor or any other health professional? If so please state who you're receiving treatment from, and what for: *NoYes

Have you previously worked night duty? If so, when did you last work nights, and for how long have you been doing this kind of work? *NoYes

If you currently take any medication, please state what you currently take and where you have been prescribed it from/where you purchase it from:

If you wish to include any further information regarding your health, please detail below:

Please let us know the name of your GP, and the name of the surgery in which they practice: *

DBS CONSENT

By signing this form you are confirming that:

- You acknowledge that in order to process your application to be employed by Nurses Alliance Limited you must have an up-to-date DBS check.

- You give your consent for Nurses Alliance Limited to take a copy or image of my original DBS certificate and hold the copy/image for as long as is necessary.

- You further acknowledge that Nurses Alliance Limited may share the information contained on the DBS certificate with a third party for the purposes of seeking guidance on the recruitment decision, where appropriate.

Nurses Alliance Limited confirms that it will comply with the DBS Code of Practice at all times. A copy of Nurses Alliance Limited policy on the recruitment of ex-offenders can be provided upon request.

Please confirm whether you have a current DBS which has been carried out within the last three years, or if you are on the DBS Online Update Service. *I have had a DBS check carried out within the last 3 years.I am on the DBS Online Update service.I do not have a current DBS.

If you are on the update service, or you have a current DBS (within the last 3 years), please let us know your DBS number as well as any other details we will need to know. Your DBS number can normally be found on the top-right of your certificate, and starts with the digits "00".

Working Time Regulations 1998

The European Union has laid down guidelines for all workers, governing the length of the maximum working week that is safe to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered you will not be be compelled to work more than 48 hours per week, however you may choose to do so.

Opt-Out Of 48 Hour Working Week

By selecting to opt-out of working more than 48 hours per week, you are agreeing to the following conditions:

1) Definitions:

In this Agreement the following definitions apply:

“Employer” means Nurses Alliance Limited, Claydon House, 1 Edison Road, Rabans Lane Industrial Area, Aylesbury, Bucks, HP19 8TE

“Employee” means (Candidate Name)

“Working Week” means an average of 48 hours each week calculated over a 17 week reference period.

References to the singular include the plural and references to the masculine include the feminine and vice versa.

The headings contained in this Agreement are for convenience only and do not affect their interpretation.

2) Restriction:

The Working Time Regulations 1998 provide that the Employee shall not work in excess of the Working Week unless he agrees in writing that this limit should not apply.

3) Consent:

The Employee hereby agrees that the Working Week limit shall not apply.

4) Withdrawal Of Consent:

The Employee may end this Agreement by giving [specify period] notice in writing.

For the avoidance of doubt, any notice bringing this Agreement to an end shall not be construed as notice of termination by the Employee.

Upon the expiry of the notice period set out in clause 4.1 the Working Week limit shall apply with immediate effect.

5) The Law:

These Terms are governed by the law of England & Wales and are subject to the exclusive jurisdiction of the Courts of England & Wales.

Should you choose to opt out of the 48 hour working week by selecting the option below, you're signing to say that you AGREE to these terms. By choosing not to opt-out of the 48 hour working week, you are signing to declare that this option has been presented to you and that it was your choice to decline.

Please tick the appropriate box to confirm that you have read and understood the above information. *I DO NOT wish to work more than 48 hrs per weekI DO wish to work more than 48 hrs per week

OVERSEAS STUDENT DECLARATION FORM

Are you an overseas student? *

All overseas students [i.e. students currenty studying in the UK that are not full UK citizens] must complete all of the below sections. If you are not an overseas student, please skip to "Confidentiality".

Name of course you are currently studying

Course start date

Course end date

Name of university/college

My visa type is:

How many hours per week are you permitted to work?

Confidentiality

If you are successful in your application for employment with Nurses Alliance Limited: All information you see or hear in the course of your duty is confidential. You must not disclose any personal details or information relating to clients, their medical conditions or information which is deemed to be commercially sensitive to the organisation.

This employment is not exempt from the provisions of the Rehabilitation of Offenders Act 1974, you are not therefore entitled to withhold information requested by the company about any previous convictions in this country or abroad you may have, even if in other circumstances these would appear spent. I confirm that the information I have given is true. I understand that if information given on the application form is found to be false it may result in disciplinary action which could include dismissal. Should I be offered employment I accept that I will be required to notify the company of any changed to my DBS status.

Data Processing

Personal information collected on this declaration will be processed and stored in full acordance with the Data Protection Act 1998 and the General Data Protection Regulation 2018. In line with the legislation Nurses Alliance Limited files are kept securely in a safe and secure location. You understand that any personal detail held by Nurses Alliance Limited may be accessed for time to time by inspectors from the care quality commision, other regulatory bodies and designated individuals in line with contractual obligations.

Employment with Nurses Alliance Limited

It is Nurses Alliance Limited policy to employ the most suitably qualified personnel and to ensure equal opportunity for the advancement of employee. This includes promotion and training and to prohibit discrimination against any individual on the basis of race, colour, ethnicity, nationally, sexual orientation, gender, religion, belief, pregnancy, marital or civil partnership status, age or disability. In completition of this application form, I authorise Nurses Alliance Limited to obtain references to support this application once an offer has been made and accepted. I release Nurses Alliance Limited and submitted referees from any liability caused by giving and receiving any information.

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

Print: *

Date: *

If 'Other' please state:

If you have been referred by a current Nurses Alliance Limited staff member, please enter their name below:

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