JOB APPLICATION FORM

Position applied for: Ref No:

Please state the location/s you are interested in working at:

PERSONAL INFORMATION
Last Name: Title: / First Names:
Address:
Postcode: / Telephone (day):
Telephone (evening):
Telephone (mobile):
Email address:
How did you find out about the vacancy? / Do you have any prior commitments or holidays booked? Please provide dates.
How will you travel to work? / If relevant, what is your notice period?
Do you have a full current driving licence?
Is it free of endorsements?
If no, please provide further details:
Do you have your own transport?
Please give details of any special interests or hobbies:
Have you previously worked for us?
If yes, please state when and in what capacity?
If offered this position, will you continue to work in any other capacity?
If yes, please provide the name and address of your employer and details of the days and hours you work:
GENERAL EDUCATION
Examination (CSE, GCSE, etc) / Subject / Grade
FURTHER EDUCATION AND PROFESSIONAL QUALIFICATIONS
Qualifications / Level and Grade
CURRENT STUDIES
Qualifications / Level / Date Commenced
PROFESSIONAL REGISTRATION
Please complete the following information where it is appropriate for the post:
NURSE POSTS
Registration body: / Registration number:
Are you currently registered: / Expiry date:
DOCTOR POSTS
GMC reference number:
Medical defence insurance policy number:
Which PCT performers list are you registered on:
EMPLOYMENT HISTORY
Please list current or most recent first:
Employer’s name and address / Position / From – to dates / Brief description of duties / Salary and grade / Reason for leaving
REFERENCES
Please provide details of two referees, one must be your current or last employer and another who knows you in connection with your work within the previous 12 months. If unemployed, please give a previous employer. Referees should not be relatives or family members. Referees will not be contacted prior to your interview.
Current or last Employer Second Referee
Name: Name:
Job Title: JobTitle:
Address: Address:
Postcode: Postcode:
E-Mail Address: E-Mail Address:
Tel. No: Tel. No:
ADDITIONAL INFORMATION
Please provide a concise account of any further information, not previously covered, that you may feel is important to support your application. This may include relevant experience, skills, knowledge, achievements, interest, personal attributes or ambitions and why you think you should be considered for this post:
REHABILITATION OF OFFENDERS ACT 1974
Some posts within Integrated Care 24 Ltd are exempt from the provisions of the Rehabilitation of Offenders Act1974. Please refer to the Job Description for further information. If the position you are applying for is exempt, you are required to declare below all criminal convictions, cautions, reprimands or final warnings, whether they are spent or unspent. If the post you are applying for is not exempt, you only need to declare belowany convictions that are not spent.
DISCLOSURE AND BARRING SERVICE CHECK
Some posts within Integrated Care 24 Ltd are subject to aDisclosure and Barring Service Checkbeing undertaken. Please refer to the Job Description for further information.
DECLARATION
I confirm that the information given in this application is correct and I acknowledge that purposely providing incorrect information may render this application and any subsequent employment invalid and be subject to summary dismissal.
I authorise the Company to obtain references to support this application once an offer has been made and accepted, and release the Company and referees from any liability caused by giving and receiving information.
Signed: ______Date: ______
EQUAL OPPORTUNITIES MONITORING FORM
Integrated Care 24 Ltd aims to be an equal opportunity employer and to select staff solely on merit, irrespective of sex, age, race, disability, religious belief or sexual orientation.
In order to monitor the effectiveness of our equal opportunities policy, we require all applicants to provide the following information. All information provided will be treated as confidential and this form will be separated from the application form upon receipt by the Human Resources Department before consideration of the candidates takes place.
NAME: POST APPLIED FOR:
Please tick the appropriate boxes:
GENDER
Male □ Female □
AGE
16-18 □ 19-34 □ 35-54 □ 55-64 □ 65+ □
DISABILITY
Do you consider yourself disabled under the Disability Discrimination Act? Yes □ No □
ETHNIC ORIGIN
I would describe my ethnic origin as:
White
English/Welsh/Scottish/Northern Irish/British □ Irish □ Gypsy or Irish Traveller □
Any other white background □
Asian or Asian British
Indian □ Pakistani □ Bangladeshi □ Chinese □ Any other Asian background □
Mixed
White and Black Caribbean □ White and Black African □ White and Asian □
Any other Mixed background □
Black or Black British
Caribbean □ African □ Any other Black background □
Other Ethnic Group
Arab □ Any other Ethnic group □
WORK PERMIT
Do you have a work permit for this country? Yes □ No □ Not applicable □
Number: ______(If you already have a permit to work in this country)
Date of renewal: ______
Are you free to remain and take up employment in the UK? Yes □ No □ Not applicable □

Documents to Confirm Eligibility to Work in the UK

In order for your job application to be considered you will need to provide evidence to confirm your eligibility to work in the United Kingdom by producing original documents at the interview stage as stated below from either List A Documents or List B Documents.

LIST A DOCUMENTS

These documents show the holder is not subject to immigration control, or has no restrictions on their stay in the UK and such employees can work for an indefinite period.

Single Documents

Any one of the following documents is acceptable:

  1. A passport showing that the holder, or a person named in the passport as the child of the holder, is a British citizen or a citizen of the United Kingdom (UK) and Colonies, having the right of abode in the UK.
  1. A passport or national identity card showing that the holder, or a person named in the passport as the child of the holder, is a national of a European Economic Area (EEA) country or Switzerland.
  1. A residence permit, registration certificate or document certifying or indicating permanent residence, issued by the Home Office or the Border and Immigration Agency (BIA) to a national of a EEA country or Switzerland.
  1. A permanent residence card issued by the Home Office or the BIA to the family member of a national of a EEA country or Switzerland.
  1. A biometric immigration document issued by the BIA to the holder, which indicates that the person named in it is allowed to stay indefinitely in the UK, or has no time limit on their stay in the UK.
  1. A passport or other travel document endorsed to show that the holder is exempt from immigration control, is allowed to stay indefinitely in the UK, has the right of abode in the UK, or has no time limit on their stay in the UK.

Document Combinations

Two documents must be produced, one from the first combination and one from the second combination.

First Combination

An official document issued by a previous employer or Government agency, e.g. HM Revenue and Customs, the Department for Work and Pensions, Jobcentre Plus, the Employment Agency (Northern Ireland) or the Northern Ireland Social Security Agency, which contains the permanent National Insurance number and name of the person.

Such documents include the following: P45, P60, NI number card, a letter from a Government agency

Second Combination

You must also provide one of the following original documents listed below in sections 7 - 13:

  1. An immigration status document issued by the Home Office or the BIA to the holder, with an endorsement indicating that the person named in it is allowed to stay indefinitely in the UK, or has no time limit on their stay in the UK.
  1. A full birth certificate issued in the UK, which includes the name(s) of at least one of the holder’s parents.
  1. A full adoption certificate issued in the UK, which includes the name(s) of at least one of the holder’s adoptive parents.
  1. A birth certificate issued in the Channel Islands, the Isle of Man, or Ireland.
  1. An adoption certificate issued in the Channel Islands, the Isle of Man, or Ireland.
  1. A certificate of registration or naturalisation as a British citizen.
  1. A letter issued by the Home Office or the BIA to the holder which indicates that the person named in it is allowed to stay indefinitely in the UK, or has no time limit on their stay.

LIST B DOCUMENTS

These documents demonstrate that the holder is entitled to work in the UK for a limited period. Should any of these documents be presented it will be necessary to conduct follow up checks every 12 months.

Single Documents

Any one of the following documents is acceptable:

  1. A passport or other travel document endorsed to show that the holder is allowed to stay in the UK and is allowed to do the work in question, provided that it does not require the issue of a work permit.
  1. A biometric immigration document issued by the Border and Immigration Agency (BIA) to the holder, which indicates that the person named in it can stay in the UK and is allowed to do the work in question.
  1. A residence card or document issued by the Home Office or the BIA to a family member of a national of a EEA country or Switzerland.

Document Combinations

These documents must be produced in the combinations specified:

First Combination

  1. A work permit or other approval to take employment issued by the Home Office or the BIA.

Evidence must also be provided to indicate that leave to enter or remain in the UK has been given by providing one of the following:

i)a passport or another travel document endorsed to show the holder is allowed to stay in the UK and is allowed to do the work in question

ii)a letter issued by the Home Office or the BIA to the holder or the employer or prospective employer confirming the same

Second Combination

The following documents are only acceptable if they have been checked by the Border and Immigration Agency Employer Checking Service:

  1. A Certificate of Application issued by the Home Office or the BIA to or for a family member of a national of a EEA country or Switzerland, stating that the holder is permitted to take employment, which is less than six months old.
  1. An Application Registration Card (ARC) issued by the Home Office or the BIA stating that the holder is permitted to take employment.

Third Combination

A document issued by a previous employer or Government agency, e.g. HM Revenue and Customs, the Department for Work and Pensions, Jobcentre Plus, the Employment Service, the Training and Employment Agency (Northern Ireland) or the Northern Ireland Social Security Agency, which contains the National Insurance number and name of the holder

Such documents include the following: P45, P60, NI number card, a letter from a Government agency

You must also provide one of the following original documents listed below in sections 7 - 8:

  1. An immigration status document issued by the Home Office or the BIA to the holder with an endorsement indicating that the person named in it can stay in the UK, and is allowed to do the work in question.
  1. A letter issued by the Home Office or the BIA to the holder or the employer or prospective employer, which indicates that the person named in it can stay in the UK and is allowed to do the work in question.

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