PLEASE COMPLETE IN BLOCK CAPITALS Layout PLEASE COMPLETE IN BLACK INK AND BLOCK CAPITALS
Position Applied for: Surname: Forenames: Title: Address: Post Code: Contact Number: * Email address: Nationality: Ethnicity: First Language/Prefer not to say Religion/ Prefer not to say
List any Academic Qualifications Institute/Location of study (a) Qualification Date (to & from) Institute/Location of study (b) Qualification Date (to & from)
Professional & Clinical Training & Qualifications Institute/Location of study Qualification Date (to & from) Qualification Institute/Location of study Date (to & from)
Note: Please bring with your original certificates of all relevant qualifications and certificates you have obtained.
Current Employment Information Name and address of current employer: Telephone Number: Name of your Manager: Start Date: End Date (if applicable): Position Held: Reason for leaving (if applicable):
Full employment history including any gaps – Most Recent First
Please note a full employment history must be provided, or your employment history since leaving full time education. All gaps in employment history must be detailed with a note of explanation. Company Name & address Position held Date from Date to Reason for leaving Company Name & address Position held Date from Date to Reason for leaving
Community, Volunteer or Intern Experience Name and Address of organisation Position & title General Duties Date (to & from)
Permissions to work in the UK Are there any restrictions to your residence within the UK that might affect your right to take up employment in the UK? If your application is successful, would you require permission to work in the UK NMC Registration Number: Expiry Date:
Proof of Professional Indemnity Insurance (if applicable) Can you provide evidence of Professional Indemnity Insurance:
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: AREAS OF EXPERIENCE KEY SKILLS AND COMPETENCE PERSONAL STATEMENT
Please provide full names and addresses of two professional employment referees and one character referee. Your first reference must be from your current or previous last place of work and addressed to your line manager. Admax Corporate 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 Name Job Title How do you know this person? Company Address Telephone Number Email How long have you known this person Name Job Title How do you know this person? Company Address Telephone Number Email How long have you known this person Name Job Title How do you know this person? Company Address Telephone Number Email How long have you known this person
Next of Kin details
(Who you would want Admax Corporate to contact in the event of an emergency) Surname: Forename: Title: Address: Post Code: Relationship: Contact Number: Work contact Number: Do you have any criminal convictions/ cautions or bind overs in the UK or abroad? (whether related to work or not): If yes please detail below: Are you / have you been under / or undergoing any clinical investigation, disciplinary or suspension process pending or otherwise? If yes please detail below:
This employment is not exempt from the provisions of the rehabilitation of young 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 changes to my DBS status.
Please tick the appropriate box to confirm that you have read and understood the above information.
If you are successful in your application for employment with Admax Corporate: 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.
Personal information collected on this declaration will be processed and stored in full accordance with the General Data Protection Regulation (GDPR). The information collected will only be used for the stated purposes. You understand that any personal detail held by Admax Corporate, may be accessed from time to time by authorised inspectors from the Care Quality Commission (CQC) and NHS Framework.
If declaration is completed during a successful job application, the declaration will be stored in an individual’s permanent employment record. If a prospective employee does not start employment the declaration will be kept for no longer than necessary and then destroyed. This is usually for a period of up to six months to allow for the consideration and resolution of any disputes or complaints. Please indicate to show your agreement
If you would like to stop receiving communications, then please contact us on 01384596056 or at email@example.com.
Health and Disability
The following questions on health and disability are asked to determine any reasonable adjustments that you may require to enable you to access our recruitment service and carry out the duties of your assignment via Admax Corporate Ltd. Do you consider yourself to be mentally and physically fit for this job given the description of the work and duties that you’ve been provided with? If you do not consider yourself to be mentally and physically fit, please specify what reasonable support you require to carry out the duties of this role. Also specify if you have any disability and what reasonable support you require to help carry out the duties of this role: If you do not consider yourself to be mentally and physically fit, please specify what reasonable support you require to carry out the duties of this role. Also specify if you have any disability and what reasonable support you require to help carry out the duties of this role:
The information you have provided on the medical questionnaire form will be used for recruitment purposes only.
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 compelled to work more than 48 hours per week, however you may choose to do so. Please indicate to confirm that you have read and understood the above information
Admax preferred payment method is via BACS. This document is vital to ensure your payments are made promptly into your account. You must complete all fields where applicable. The account details must be your own personal account or the Limited company through which you are working (you must be a director of the company you are working through).
BANK SORT CODE BANK ACOUNT NUMBER ACCOUNT NAME BANK/BUILDING SOCIETY NAME ROLL NUMBER
Employment with Admax Corporate
It is Admax Corporate 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, nationality, sexual orientation, gender, religion, belief, pregnancy, marital or civil partnership status, age or disability. In completion of this application form, I authorise Admax Corporate to obtain references to support this application once an offer has been made and accepted. I release Admax Corporate and submitted referees from any liability caused by giving and receiving any information.
I 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. Signed: Date: How did you hear about Admax Corporate? Please provide detail: e.g. online