EPlough Registration Form

EPLOUGH AGENCY WORKER REGISTRATION FORM
Name*

First NameLast Name
Job Title
Date of birth*

DayMonthYear
Date
If you have been known by any other name(s), please state it below:
Registrant Email Address*
example@example.com
Your Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Mobile Phone Number*
Please enter a valid phone number.
Marital Status
Do you hold a current driving licence?

YesNo
NI Number
Nationality*
Country of Current Nationality
In accordance with the Disqualification from Caring for Children Regulations 2002, have you ever had a child removed from your*

YesNo
Declaration of Criminal Convictions In order to protect certain vulnerable groups with society, there are a number of posts and professions that are exempt from the provisions of the Rehabilitation of Offenders Act 1974. These include posts where in the normal course of duty, employees have access to persons requiring care. Under the Exceptions Order (1975), applicants are obliged to disclose information about any convictions which for other purposes would be regarded as 'spent'. Failure to disclose such convictions could result in dismissal or disciplinary action by the employing organisation. Any information given will be confidential and will be considered only in relation to any posts to which the conviction applies. Have you, at any time, received, or had pending, a court conviction in the UK or overseas?*

YesNo
CHECKLIST

In order to process your application smoothly, please ensure you enclose ALL documents/information as detailed below, where applicable with your application.

Last 3 years' worth of references or 2 most recent and relevant. 1 must be most recent employer
Passport Photograph (Light Background)*
CV Upload*

Please upload a current copy of your CV
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Right to Work Documents*

Please upload a current copy of your 1) UK right to Work. Passport/ BRP/ Visas Both Pages 2.) Proof of National Insurance Number
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Upload your Share Code

For share code visit: https://right-to-work.service.gov.uk/rtw-prove/id-question
Cancelof
Proof of Address (Within Last 3 Months)*

Driving License / Utility Bills/ Bank Statement
Cancelof
Qualifications Upload

1.) Qualifications and Certificates (Professional Registration Certificate, Degree and BLS/ALS/PALS certificate as appropriate) 2.)Current DBS Disclosure *Must be registered on the Update Service 3.) Overseas Police Check/Certificate of Good Conduct (if you have been outside the UK for more than 3 months over the past 5
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Payment Frequency

WeeklyMonthly
Account Holder Name
Bank Name
Account Number
Sort Code
Next of Kin: Name and Address
Next of Kin Telephone number
Next of Kin Email address
example@example.com

Professional Registration - HCPC Professionals only
Position Applied for
HCPC Profession
HCPC Registration Name
HCPC Registration Number
Registration Status
Registration Period
Professional Registration - Nurse/Midwife Only
Position Applied for
Main Specialism
NMC registration number
Appraisal Management
Renewal Date

MonthDayYear
Date
Nominated Appraiser Contact details
Practice Insurance: Name and Policy Number
Practice Insurance Expiry Date (If Applicable)

MonthDayYear
Date

Please include both educational and vocational qualifications starting with the most recent and going backwards in time.

Please detail your full employment history of the last 10 years, starting with your most recent employer (stating if it was a recruitment agency), and continuing backwards in time. Please ensure that dates provided include both month and year. Continue on separate page if necessary.
Current Employer Company Name
Start Date of Employment (1)

MonthDayYear
Date
Job Title
Reasons for Leaving
Salary on Leaving
Notice Period (if relevant)
Duties / Responsibilities of Role
Employer (2): Company Name
Dates of Employment (2)

MonthDayYear
Date
Job Title (2)
Reasons for Leaving (2)
Salary on Leaving (2)
Duties / Responsibilities of Role (2)
Company Name (3)
Start Dates of Employment (3)

MonthDayYear
Date
Job Title (3)
Salary on Leaving (3)
Reasons for Leaving (3)
Duties / Responsibilities of Role (3)
Dates of Employment (3)

MonthDayYear
Date
REFEREE 1 Please disclose last 5 years' worth of referee details or 2 recent and relevant references - 1 from most recent employer All referee details must be from a person in a more senior/managerial position. (We reserve the right to contact all previous employees)*
Position
Name of organisation/school/college
Telephone Number
Email Address (Ref 1)*
example@example.com
REFEREE 2 Please disclose last 5 years' worth of referee details or 2 recent and relevant references - 1 from most recent employer All referee details must be from a person in a more senior/managerial position. (We reserve the right to contact all previous employees)*
Name of organisation/school/college
Position
Telephone Number
Email Address (Ref 2)*
example@example.com

Qualifications / Mandatory Training
Mandatory Training

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Do you hold a current UK police check (DBS)?

YesNo
If "yes', please provide the following details
Issue date

MonthDayYear
Date
Issued by
DBS Upload

Upload a copy of your DBS File
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Have you subscribed to the DBS Update Service?

YesNo

Declaration: The information in this form is true and complete. I understand that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application form or subsequent dismissal if employed by the organisation. I acknowledge that my personal details will be stored and handled by Eplough Consulting Ltd in accordance with the Data Protection Act 1998. I agree that the company may forward my details to prospective employers in capacity as an agency. I give consent for Eplough Consulting Ltd to contact me from time to time regarding market research and new opportunities. I authorise Eplough Consulting Ltd to obtain any relevant references and verification of qualifications on my behalf. I confirm that I am not currently disqualified from working with children or vulnerable adults, or subject to any sanctions imposed by a regulatory or professional body and if these circumstances were to change, I understand I must inform Eplough Consulting Ltd immediately. Any changes to information on my current DBS that has not already been disclosed will also be disclosed to Eplough Consulting Ltd immediately. Eplough Consulting Limited is able to upload the applicant's copy of your DBS onto the Vendor Managed Systems (VMS) that currently holds a number of contracts Nationwide in order to gain new employment. I agree for Eplough Consulting Ltd to conduct Update Service checks against my DBS regularly as part of the safeguarding process. (If applicable)I agree for Eplough Consulting Ltd to share my application documents with third parties for audit purposes. Working Times Regulations 1998 requires Eplough Consulting Ltd to ensure all agency workers complete no more than 48 hours work per week. If you wish to opt out of this, please tick yes.*

YESNO (Maximum of 48 Hours Weekly)
Signature*

Clear
Print Name
Date

MonthDayYear
Date
Should be Empty:

EPLOUGH AGENCY WORKER REGISTRATION FORM