Application Form (The Healthcare Agency London)

The Healthcare Agency London
APPLICATION FORM
Title
Full Name*

First NameSurname/Family Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Telephone Number*
Please add country code eg +2348097658789, +447942245765
Position to be considered for?
Marital Status
Nationality*
Country of Residence*
The Healthcare Agency London is committed to Equal Opportunities in Employment and as part of this policy, all applicants for employment are asked to complete the details requested below. The information will only be used for the purposes of monitoring the policy except where expressly stated otherwise. The information it contains will not be used in deciding whether or not to invite you to interview or offer you employment. As an Equal Opportunities Employer, The Healthcare Agency London aims to ensure that no job applicant or employee receives less favorable treatment on the Grounds of age, race, colour, sex, marital status, religion, ethnic origin, nationality, disability or sexual orientation. Please help us to achieve our aim by completing the following questions:
What is your ethnic group? Please choose to indicate your cultural background.
NoneFull UK Drivers LicenceProvisional UK Drivers LicenceInternational Drivers Licence
Are you related to any former or existing employee of The Healthcare Agency London?
If YES, please give details
How did you hear about us?
Who referred you? Please state the agency or name of the person below.
If Applying from the UK

This section only applies to candidates who are already in the United Kingdom
Name/Type of Current Visa
Do you have an active BRP?
Expiry Date of BRP?
Do you currently have a CoS?
Other Information on your immigration status and why you are applying for a job

EMPLOYMENT HISTORY
Name of current or most recent employer*
Full Address
Job Title
Current salary
Date started in post

MonthDayYear
Date
Date of leaving (if relevant)

MonthDayYear
Date
Notice required
Brief description of your main duties and responsibilities
Reason for leaving

EDUCATION DETAILS
Kindly upload your up-to-date CV (Resume)*

Cancelof
OTHER RELEVANT TRAINING AND/OR SHORT COURSES OR PERSONAL DEVELOPMENT OR LIFE SKILLS.
Examples could include short internal or external courses, voluntary work and work experience.
Do you have your IELTS Result or NARIC?
Will you continue to undertake any other job if you are offered this Job Position?
Available to take up Employment from

References
Please give details of two employment referees, one of whom must be your current or most recent employer. If you have not held a position of paid employment, you may give details of someone connected with you in any unpaid or voluntary work you have undertaken, or any period of study. We reserve the right to contact any previous employer(s) listed on this form should it be deemed necessary by The Healthcare Agency London.
REFERENCE ONE
Name
Company Name
Position of Referee
Email Address of Referee
example@example.com
Contact No of Referee
Address
REFERENCE TWO
Name
Company Name
Position of Referee
Email Address of Referee
example@example.com
Contact No of Referee
Address

CONVICTIONS
Rehabilitation of Offenders Act (1974)

This post is offered subject to a satisfactory enhanced Disclosure and Barring Service (DBS) check and is exempt from the provision of Section 4 (2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as amended by the Exceptions (Amendment) Order 1986. Applicants are not entitled to withhold information when asked about convictions which for other purposes are "spent' under the provision of the Act. In the event of employment any failure to disclose such convictions could result in dismissal or disciplinary action. Information given will be completely confidential.
Have you ever been convicted in a Court of Law and/or cautioned in respect of any offence?
If YES, please give details
Do you have a Police Report in your country of residence?
HEALTH RECORD
The Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) Regulations 2021 ("the Regulations) were made on 22nd July 2021. These regulations require registered persons of all CQC registered care homes to ensure that a person does not enter the indoor premises unless they have been vaccinated. The Healthcare Agency London is obliged to follow this directive and as such will need you to disclose you vaccination status.
Have you had your COVID 19 vaccine?
Date of first dose

MonthDayYear
Date
Type of vaccine
Where Vaccinated?
Date of second dose

MonthDayYear
Date
Type of vaccine
Where Vaccinated?
If you haven't had your vaccine, when do you plan to have your first dose

MonthDayYear
Date
Have you done your TB Test?

DECLARATION
IMPORTANT INFORMATION AND DECLARATION

Appointment is subject to the following: Health Clearance, Criminal Records Enhanced Disclosure (where appropriate), satisfactory References, evidence of Eligibility to work in the UK, Qualification (s) and Membership or registration of relevant professional body. In completing and returning this application, you are consenting to the processing of data therein and that this will comply with the Data Protection Act 1998. I declare that all the information I have included on this form is true to the best of my knowledge and without omission of any facts that could have a bearing on selection decisions. I understand that any appointment is conditional on this declaration. I also understand that if I am offered a position by Purer Healthcare Agency, this offer may be withdrawn if subsequently any of this information is found to be incorrect or incomplete. In addition, I am aware, should this situation occur after I join the employment of The Healthcare Agency London, I will be liable to disciplinary action, and this could lead to dismissal.
Today's Date*

MonthDayYear
Date
Print Name in Full*
Should be Empty:

The Healthcare Agency London

APPLICATION FORM

If Applying from the UK

EMPLOYMENT HISTORY

EDUCATION DETAILS

References

REFERENCE ONE

REFERENCE TWO

CONVICTIONS

HEALTH RECORD

DECLARATION