Z 1 New Job Application Form

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Position Applied For *

e.g. RMN, RGN, Registered Manager, Support worker, HCA, Cleaner, Activity Co-ordinator, Chef

Are You Employee or Self Employee *

Employee
Self Employed

if you are Self Employed You Must Provide UTR Number

Title *

Photo *

Click or drag a file to this area to upload.

Only Passport Size Photo Allow

First Name *

Middle Name

You can write "Not Applicable" for No Middle Name

Last Name

You can write "Not Applicable" for No Last Name

Date Of Birth *

Marital Status *

Gender *

Contact Details And Address

Email *

Mobile Number *

Home Number

Address Line 1 *

Address Line 1

Address Line 2

City / State *

Postcode *

Country *

Save and Resume Later

SECONDARY CONTACT

Next Of Kin *

Relationship *

Phone Number *

Email *

Address Line 1 *

Address Line 2

City / State *

Postcode *

Country *

For Professional Nursing Application

Registered As *

PIN *

Expiry Date *

Date must be in DD / MM / YYYY format

UTR Number *

You selected Self Employed, You Must Enter Your UTR Number https://www.gov.uk/find-utr-number

Right To Work

National Insurance Number *

BRP (Biometric residence permits) No *

Passport *

British Citizen
European Union
Foreign National

Passport Issue Country *

UK Entry Clearance VISA / Residence Permit *

Indefinite Leave to Remain
Healthcare Worker Visa
Spouse Visa
Student Visa

Driving Records

Do you hold a current driving licence? *

Driving Licence Type *

Full
Provisional
Other

Do you own a car? *

Driving licence Number *

Driving Licence Valid from *

Driving Licence Valid to *

Date must be in DD / MM / YYYY format

Details of current endorsement

Save and Resume Later

Education History *

10th Standard / GCSE
12th Standard / A Level
Bachelor Degree
Master / DR Degree
PhD
Other

(Latest First)

School Name *

10th - 12th

Course Name

CBSE

Start Month + Year *

Course Enrolment Month and Year

Graduate Month + Year *

Course Completion Month and Year

Qualification Gained - Grade *

School Name *

10th - 12th

Course Name *

CBSE

Start Month + Year *

Course Enrolment Month and Year

Graduate Month + Year *

Course Completion Month and Year

Qualification Gained - Grade *

College / University Name *

Bachelor Degree

Course Name *

Start Month + Year *

Course Enrolment Month and Year

Graduate Month + Year *

Course Completion Month and Year

Qualification Gained - Grade *

College / University Name *

Master Degree

Course Name *

Start Month + Year *

Course Enrolment Month and Year

Graduate Month + Year *

Course Completion Month and Year

Qualification Gained - Grade *

College / University Name *

Course Name *

Start Month + Year *

Course Enrolment Month and Year

Graduate Month + Year *

Course Completion Month and Year

Qualification Gained - Grade *

Other *

Other

Start Month + Year *

Course Enrolment Month and Year

Graduate Month + Year *

Course Completion Month and Year

Qualification Gained - Grade *

Education Gap

If you have any Education Gap Explain

Employment History

Any Gap must be Explained.

Select Employment History *

Employment History 1

Start Month *

Start Year *

End Month *

Select "Currently working" if you working with your Current Company

End Year *

Job Title *

Name of Employer (company Name) *

Address of Employer *

Hourly / Monthly Pay Rate *

Duties and Responsibilities *

Reason for Leaving *

Employment History 2

Start Month *

Start Year *

End Month *

End Year *

Job Title *

Name of Employer (Company Name) *

Address of Employer *

Hourly / Monthly Pay Rate *

Duties and Responsibilities *

Reason for Leaving *

Employment History 3

Start Month *

Start Year *

End Month *

End Year *

Job Title *

Name of Employer (Company Name) *

Address of Employer *

Hourly / Monthly Pay Rate *

Duties and Responsibilities *

Reason for Leaving *

Employment History 4

Start Month *

Start Year *

End Month *

End Year *

Job Title *

Name of Employer (Company Name) *

Address of Employer *

Hourly / Monthly Pay Rate *

Duties and Responsibilities *

Reason for Leaving *

Employment Gap

Any Gap must be Explained.

Save and Resume Later

Work Preference

Please keep us informed from time to time of all developments in your career as the work we assign to your depends on accurate up to date information.

Work Preference *

Full Time
Part Time

48 hours opt in *

opt in

48 hours opt in or opt out *

opt in
opt out

Work Preference

Nursing
Residential Homes
Supported Living

Experience

Mental Health
SCBU
Oncology
Neurology
ENT
Recovery
Terminally III Care
Dermatology
Community Nursing
Anaesthetics
Burns & Plastic
Phlebotomy
Elderly Care
Hospice Care
Genito-Urinary
Cardio-Thoracic
Psychiatry
Practice Nurse
Learning Disability
A & E
Liver unit
Dental Nursing
Orthopaedics
Occupational Health
Midwifery
Intensive Care
Renal, Haemo, Peritoneal Dialysis

Indicate any other area not listed above:

Work Preference

Please indicate Yes/No in the areas you have had previous experience.

Care Duties *

Personal Care / Hygiene *

Bath / Shower / Strip Wash *

Pressure area care *

Bed bath *

Simple dressing procedure *

Use bath aids *

Assisting with medication *

Shaving *

Terminal care *

Mouth care(inc. denture) *

Light housework *

Care of hair *

Care of feet (exe. toe nails) *

Washing Personal laundry *

Dressing / Undressing *

Shopping *

Bed making / changing bed linen *

Report writing *

Recording instruction from GP / District Nurse *

Observing / Recording *

Use of walking aids *

Use of hoists (Manual / Electric) *

Supported Living *

Private house *

Nursing homes *

Mobility *

Pre-Employment Declaration of Health

Have you ever suffered from any of the following?

Heart / Circulatory / Hypertension *

Diabetes *

Bronchitis / Pneumonia / Pleurisy *

Epilepsy *

Headaches / Migraine *

Tuberculosis *

Psychiatric Illness / Anxiety / Depression *

Dermatitis / Psoriasis / Eczema *

Back problems *

Recurrent infections *

Hepatitis / Jaundice *

Are you taking any prescription drugs? *

If you have answered yes to any of the above questions please give details here.

Have you ever been vaccinated, immunised or tested for / Again any of following:

Varicella *

Tuberculosis Including BCG *

Heaf, Mantoux or time *

Rubella (German Measles) *

Poliomyelitis *

Hepatitis B *

Hepatitis *

HIV *

Tetanus *

Typhoid *

Any other please state:

References Details

We require reference covering 5 Years (or a minimum of two previous employers)

Please provide details of two referees who can provide information relating to your competency in your Role. The referees should be someone that managed you. Referees should be of two different employers. If you are not able to provide two different employers please provide a third reference which would need to be a Character referee or someone which holds a professional position that is not related to you.

Referee 1 : Do not contact before interview

Company Name *

Employee Name *

Position Held *

Phone Number *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Referee 2 : Do not contact before interview

Company Name *

Employee Name *

Position Held *

Phone Number *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Consent *

I consent NOVA HC Services to contact the references provided for the purpose of employment verification.

Contact References *

Before interview
After Interview

Bank Details

Name of Bank *

Account Holder Name *

Sort code *

Account No *

Equal Opportunities monitoring Form

This information will be separated from your application form upon receipt. It is not part of your application and will not be used in any part of selection process. NOVA HEALTHCARE SERVICES LTD strives to be an equal opportunities employer and has a clear policy in terms of challenging discriminatory practices. In order to have accurate information about our performance we would be grateful if you would complete this monitoring form and return it with your application form. The information will stored anonymously and confidentially.

If you would prefer not to give your ethnicity please check this box

If you would prefer not to give your ethnicity please check this box

Ethnicity *

Asian or Asian British
Black or Black British
Chinese
Mixed
White
Other ethnic group

Asian or Asian British *

Bangladeshi
Indian
Pakistani
Any other Asian background

Select only one

Black or Black British *

African
Caribbean
Any other black background

Select only one

Mixed *

White and Black Caribbean
White and Black African
White and Asian
Any other mixed background

Select only one

White *

British
Irish
Any other white background

Select only one

Please specify

Asian or Asian British

Please specify

Black or Black British

Please specify

Chinese

Please specify

Mixed

Please specify

White

Please specify

other

If you Would like to further describe your ethnicity, please do so here:

Disability

If you would prefer not to say please mark this box

Do you consider yourself to be a person with a disability? *

Under the Equality Act 2010 a person is classified as disabled if they have a physical or mental impairment has a substantial and long term effect on their ability to carry out.

If you would prefer not to say please mark this box

Are you carer *

A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support.

Please tell us how you heard about us *

if you feel that our recruitment procedure has been unfair please tell us at: info@novahc.co.uk

Cautions, Rehabilitation and Criminal Records

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 Exceptions Order 1975 as amended by the Exceptions (Amendment) Order 1986, which means that convictions that are spent under the terms of the Rehabilitation of Offenders Act 1974 mustbe disclosed, and will be taken into account in deciding whether to make an appointment. Any information will be completely confidential and will be considered only in relation to this application.

In addition you are required to submit to an ACCESS NI check. Any standard or enhanced disclosure made by the ACCESS NI will remain strictly confidential.

Have you ever been conuicted in a Court of Low and/or cautioned in respect of any offence? *

Are you currently the subject of a potes investigation or have any prosecutions pending? *

If you have answerd yes to any of the above please give details *

DECLARATION

(Please read this carefully before signing this application)

1. I confirm that the above information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.

2. Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my personnel file during employment and for up to six years thereafter and understand that information will be processed in accordance with Data Protection Act.

3. I agree that should I be successful in this application, I will, if required, apply to the Disclosure and Barring Service Office for an enhanced disclosure. I understand that should I fail to do so or should the disclosure not be to the satisfaction of the company any offer of employment may be withdrawn or my employment terminated.

GDPR Agreement & Right to Audit Declaration *

I hear by provide consent for my personal file (which could include special categories of personal data user Data Protection Laws) to be shared with the clients and their third-party auditors. Data will include (but is not limited too): References and Employment History; Criminal Record Check; Identity and Right to Work; Professional Registration and Qualifications, Training, Fitness to Work and any other information relevant as part of my registration and engagement through the clients, including Application and Interview Forms.

*Special Category data may include the following:*
-> Personal data revealing racial or ethnic origin;
-> Personal data revealing religious or Philosophical beliefs;
-> Personal data revealing trade union membership
-> Biometric data (where used for identification purposes);
-> Data concerning health;
-> Data concerning a person's sexual orientation

Furthermore, I acknowledge that my information may be passed on to and / or verified with third party organisations throught the course of the audit.

I note that I may withdraw my consent at any time.

I accept the general terms and condition of use www.novahc.co.uk *

I accept the general terms and condition of use www.novahc.co.uk

I accept the Privacy Policy of www.novahc.co.uk *

I accept the Privacy Policy of www.novahc.co.uk

Full Name *

Enter Your Full Name

Signature *

Clear Signature

Current Date *