Personal Details

Next of Kin

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 indicate which days you would prefer to work:

Education/Qualifications

Start with the most recent:

Convictions/ Disqualifications

To ensure the safety of our clients an Enhanced DBS (formerly CRB) checks must be completed for all positions. A criminal record will not necessarily be a bar to obtaining a position with Mishlaiz Versatile Healthcare Ltd. If a check is returned and reveals any information, this will be discussed with the applicant. The Director(s) will decide as to whether the offer of employment should be withdrawn.

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

1986 We would draw your attention to the following statement:

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.

References

Bank Details

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 the Mishlaiz Versatile Healthcare Ltd that this limit should not apply.

Mishlaiz Versatile Healthcare Ltd

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 Mishlaiz Versatile Healthcare Ltd 4 weeks written notice.

If you accept this proposal, please sign below. This section of the application form will then be a record of this agreement between you and Mishlaiz Versatile Healthcare Ltd

Equal Employment Opportunities Monitoring Questionnaire (strictly confidential)

Mishlaiz Versatile Healthcare Ltd is an equal opportunities employer and will ensure that no job applicant or employee receives less favourable treatment particularly on the grounds of sex, race, colour, nationality, ethnic origin, marital status, disability, sexuality, age, religious belief, political belief, trade union activity, responsibility for dependants, employment status or HIV status.

Please complete this form and return it with the main Application Form to assist Mishlaiz Versatile Healthcare Ltd in monitoring its Recruitment and Selection process. In addition, the information will form part of the employment record for the successful applicant and will be used by Mishlaiz Versatile Healthcare Ltd for later equal opportunities monitoring purposes throughout the period of employment.

This form is not made available to those conducting the recruitment interview.

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.

You are required to complete the Health Self Declaration Assessment below which must be signed and returned to Mishlaiz Versatile Healthcare Ltd prior to the start date.

Do you have any of the following?

As a health care worker, you are under ethical and legal duties to protect the health and safety of the individuals in your care. All information disclosed will be processed in accordance with the requirements of the Data Protection Act

Nursing and Allied Professionals Only: