Personnel Application Form

In order to work in the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser” Please give details below of the Senior Practitioner who you have made arrangements with to act as your appraiser

All applications who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost. Worldclass Care Services will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate.

Candidates will be required to purchase uniform if required at the cost of £20 this will be deducted from your timesheet once you have started working through us. Please fll in the box below stating your uniform size and quantity.

Please ensure you complete this section even if you have a CV. The NHS states that “Employment history should be recorded on an Application Form which is signed” Please ensure that you leave no gaps unaccounted for and it covers full work history including your education. Please use extra paper if required

Full work history including your education
Dates to and from are shown in a mm/yy format
Dates are continual with NO gaps
Where there have been gaps in work history please state the reason for the gaps
Lists all relevant training undertaken

For the purposes of the Working Time Regulations 1998 (as amended) I, consent to work in excess of an average of 48 hours per week, averaged over 17 weeks. I understand that I may withdraw this consent by giving Worldclass Care Services not less than three months’ notice at any time.

In addition, I also consent to work in excess of the maximum number of hours permitted to work at night under the directive. Please note you are under no obligation to sign either declaration.

All applicants must complete the enclosed health questionnaire to enable us to establish your ftness for work. We would ask all OVERSEAS candidates to provide a medical statement from their GP or medical department confrming your state of health. Your details will be passed to our Occupational Health Doctors to establish your ftness for work. Please sign the declaration below to allow Worldclass Care Services to release your information for inspection.

I (name) consent to Worldclass Care Services. Recruitment releasing my health and immunisation records for review to Worldclass Care Services qualifed Occupational Health Advisor. I understand that based on this review I may be required to undergo a medical examination to establish my ftness for work. I confrm that I will immediately inform Worldclass Care Services. Recruitment in confdence if I am HIV Positive, HepB positive or if I have AIDS in accordance with the Department of Health guidelines. I am aware of my obligations regarding MRSA contact and the need for screening. I agree to immediately inform Worldclass Care Services. Recruitment should my general condition of health change. I will inform Day Worldclass Care Services. Recruitment immediately if I discover that I am pregnant. I understand that withholding information or giving false answers may lead to dismissal. I also hereby consent to Worldclass Care Services. obtaining further information regarding my health from my GP or Occupational Health Department.

I hereby confrm that the information provided on my application is correct and true to the best of my knowledge and that I have not withheld any information that should be taken into account when offering me work

I understand that providing false or inaccurate information may result in the termination of any placement

I agree that I will make best endeavors to make myself aware of the Health & Safety procedures for each client I am assigned to.

I confrm that I have read and understood the Terms of Engagement and the terms of the declaration and agree to be bound by them.

I hereby declare that at no time will I divulge to any person, nor use for my own or any other person’s beneft, any confdential information in relation to the Client or the Company Worldclass Care Services Recruitment) or in relation to any of their employees, business affairs, transactions or fnances which I may acquire during the term of my agreement with the Company (Worldclass Care Services) under the Terms of Engagement.

Because of the nature of the work for which you are applying , Section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 apply. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confdential and will be considered only in relation for positions to which the order applies.

If yes please give details

If yes please give details

If yes please give details

(for candidate registered on the update service only)

Each agency worker has a responsibility at the start of their frst shift to become familiar with the Client’s general policies including, without limitation, those relating to Crash Call Procedures, the Hot Spot Mechanism for alerting security sta that an individual is in trouble, Fire Policy and the Violent Episode Policy

NB Nurses & ODP’s only: Please tick this box to confrm you hold your own indemnity insurance.

All Nurses need to have in place an indemnity arrangement as a mandatory requirement of the NMC Code.

It is the professional responsibility of each nurse and midwife to ensure that they have cover which is appropriate to their role and scope of practice and its risks. It is your sole responsibility to ensure that indemnity insurance does not expire.

The cover that they have in place should be relevant to the risks involved in their practice, so that it is reasonably suffcient in the event that a claim is successfully made against them.

I give consent for WorldcLass Care Services to use an identifcation document scanner required for NHS frameworks.

I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Offce or any other relevant authority. If I have secured permission to work, I have included copies of all documentation. I also acknowledge that if it is found that I am working without the relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities.

I agree that Worldclass Care Services retains the right to hold this registration form and any other data required to process it and pass onto any authorised third party and the details held within. I also agree to use all reasonable efforts to assist to comply with the Data Protection Act 1998.

In addition, I confrm that that all the information provided is true and accurate and that I have received and agree to Worldclass Care Services Recruitment terms of engagement and Sta Handbook.

I Please select the option which best Please indicate your religion or belief describes your sexuality