CT STAFFING Application form
Please complete all the sections and upload required documentations
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Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Of Birth
-
Month
-
Day
Year
Date
Nationality
National Insurance Number
Do you require a work permit to work in the UK?
Yes
No
Are you a student? (If yes please provide details below)
Yes
No
Other
Name of College/University
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Employment History
Most recent job and role
Company Name
Position held
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date employed From
-
Month
-
Day
Year
Date
Date employed to
-
Month
-
Day
Year
Date
Reasons for leaving
Summary of responsibilities and/or achievements
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Employment History
Company Name
Position held
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Date employed from
-
Month
-
Day
Year
Date
Date employed to
-
Month
-
Day
Year
Date
Reasons for leaving
Summary of responsibilities and/or achievements
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Professional/Vocational Qualifications
Qualifications
Rows
Qualifications gained e.g NVQ, QCF, or Other relevant care/dental qualifications
Dates obatined
Awarding/Statutory Body
Registration No.
1
2
3
4
5
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GDC Registration
Pin no
Expiry date
-
Month
-
Day
Year
Date
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Personal statement
This part of the application form gives you an opportunity to provide further information in support of your application. Please state how previous and present experience enables you to satisfy the essential and desirable criteria on the person specification.
Statement
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References
Please state below the names and addresses of two referees (including your current or last employer) and covering at least three years of employment. These people will only be contacted if a job offer is made and verbally accepted by you. Referees should not be relatives or personal friends. We reserve the right to contact any previous employer or education establishment mentioned on this application.
Employer Referee 1
First Name
Last Name
Job title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Referee 2
First Name
Last Name
Job title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Criminal Convictions/Probity Declaration
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 (Exceptions) Order 1975. Applicants are therefore not entitled to withhold information about convictions or cautions which for other purposes are “spent” under the provisions of the Act, and in the event of employment, any failure to disclose such convictions or cautions could result in dismissal or disciplinary action by the Agency. Any information given will be completely confidential and will be considered only in relation to applications for positions to which the Order applies.
Details of convictions (if any)
Do you have any criminal convictions that have not become spent under the Rehabilitation of Offenders Act 1974 and/or any offences for which
Yes
No
Have you ever been disqualified from the practice of a profession or required to practice under specific limitations?
Yes
No
Do you have any cautions that have not become spent under the Rehabilitation of Offenders Act 1974 and/or any offences for which? you are currently awaiting a Court appearance?
Yes
No
Has your employment or contract ever been terminated or suspended – in the UK or abroad – on grounds relating to your fitness to practice
(conduct or performance?) Yes
No
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Data Protection Act 1998
This application form has been designed to provide us with sufficient basic information to carry out a preliminary assessment of your suitability for the post. The information you supply in this form is confidential and will only be used by those involved in the appointment in line with the Data Protection Act 1998.
How did you hear about this vacancy?
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Declaration
By signing below, I confirm that the information given on this form is, to the best of my knowledge, complete and correct. I understand that any incorrect or incomplete information may lead to my application being refused, my offer of employment being withdrawn, or termination of my employment should I have commenced work.
Name
First Name
Last Name
Date completed
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Month
-
Day
Year
Date
Signature
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