Application for Employment (Regulated Activity)
All information will be treated as Strictly Confidential and no approach will be made to any person without your permission. Please print clearly if completing by hand.
Were you referred to CLCA? If so, please state the name.
Position applying for
If applying for RGN, provide your PIN & Revalidation Renewal Date
If you obtained this position, would you continue in any other employment?
Do we need to make any disability-related adjustments to allow you to take part in the recruitment process?
Are you entitled to enter or remain in the UK and undertake the work in question?
Street Address Line 2
State / Province
Postal / Zip Code
What languages do you speak?
Do you have any links to the Armed Forces, for example family members or friends?
If Yes, please detail
Education and Training
Please detail any further information you wish to put forward in support of your application. This section can also be used to explain any gaps in employment.
Employer References (please cover the last 2-year period)
Periods worked (from and to)
Contact Email Address
Contact Phone Number
Personal Reference (not to include family / friends)
Question asked under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Do you have any physical or mental health conditions which are relevant to your capability, after reasonable adjustments are made, to properly perform the tasks which are intrinsic to this employment?
We process personal data relating to those who apply for job vacancies with us or who send speculative job applications to us. We do this for employment purposes, to assist us in the selection of candidates for employment and to assist in the running of the business. The personal data may include identifiers such as name, date of birth, personal characteristics such as gender, qualifications and previous employment history. We will not share any identifiable information about you with third parties without your consent unless the law allows or requires us to do so. The personal data provided during an application process will be retained for a period of at least six months or, if required by law, for as long as is required. This privacy notice does not form part of an employment offer or contract between us. If we make an employment offer to you, we will provide further information about our handling of your personal information in an employment contract separately. If you would like to find out more about our data retention policy and how we use your personal data, you want to see a copy of the information about you that we hold or have any questions or issues regarding data protection, please email us with the subject “Data Protection Request”.
I give my permission for you to approach my Referees?
I confirm that the above information is true. I understand that any job offers made on the basis of untrue or misleading information may be withdrawn or my employment terminated.
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