Staff Application Form

The recruitment process within GA Professional Healthcare has a minimum of two stages.

The completion of this application form is part of stage one. This application will be reviewed and a decision will be made as to whether to proceed to stage two, the interview, based on this information.
Staff Application Form

Personal Information
Date of birth

DayMonthYear
Phone Number*

E.g, +44Phone Number
Address*

House Number and Street Address

Street Address Line 2

CityState / Province

Postal/Zip CodeCountry
Email*
National Insurance Number (NI)
Moved to this address on the date

DayMonthYear
Address

House Number and Street Address

Street Address Line 2

CityState / Province

Postal/Zip CodeCountry
Moved to this address on the date

DayMonthYear
Position applied for*
What is your Nursing Pin?
Please tick which you would prefer
Please tick which shifts you are available to work?

DaysNightsWeekends onlyLive-in
Approx. no of hours wanted (weekly)
Do you hold a current full driving license?
How long has your license been held (Date of Issue)

DayMonthYear
You will be required to upload a copy of your driving license
Next of Kin (Name)*

First NameLast Name
Relationship with Next of Kin*
NOK Email*
Phone Number*

E.g, +44Phone Number

Capacity to work in the UK
Note: Minimum age legislation dictates that care workers in general must be 18 years old or older, and Carers working with people with learning disabilities must be 21 or older. Please inform your interviewer immediately if you do not meet these specifications.
Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?*
If yes, please provide details
If you are successful in the application, would you require a work permit prior to taking up employment?*
If yes, please provide details

Health Details
GA Professional Healthcare has a policy of interviewing applicants who have a disability and who meet the essential short-listing criteria. In order to ensure that this happens, please answer the following questions:
Do you have any mental or physical disability or illness (currently or recurring) which is relevant to the post for which you are applying?*
If yes, please provide details
Have you had any absences from work in the last 12 months, except holidays:*
If yes, please provide details
Have you had any illnesses/accidents/injuries in the last 2 years:*
If yes, please provide details
GP Name (Surgery/Doctor)
(Your GP will not be contacted without your permission)
GP Phone Number

Area CodePhone Number
GP Address

House Number and Street Address

Street Address Line 2

CityState / Province

Post Code

Training & Educational History
Education History
Training History/Professional Status
Shorts Courses Attended

Employment History
Current/most recent first. Information must cover the whole of your working life to date. State the reasons for any breaks in employment. You will be required to upload a copy of your CV as a supporting evidence for your professional and educational history.
Current or most recent Employer
Company/Organization Name*
Address*

House Number and Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Nature of business*
Position held*
Date employed*

DayMonthYear
Are you still employed by this company/organisation?*
Employment End Date

DayMonthYear
Reason for Leaving*
What was your Salary Range?
Employer prior to the one above
Do you have any relationships with any director or have a relationship ith director or employee of GA Professional Health Ltd?*
Do you have any gaps in your employment history?*
If yes, please specify the gaps below
Format: Dates of gaps - reason. Example (March 2021 - April 2021) - (Child Birth/Maternity Leave)

Relevant work experience
Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home.*

References
You must provide references from your two most recent employers. Please provide an additional character referee. All will be contacted, therefore please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.
Current or most recent Employer
Name of Organization*
Name of Contact Person*

First NameLast Name
Job Title*
Email*
Phone Number*

E.g, +44Phone Number
Address*

House Number and Street Address

Street Address Line 2

CityState / City

Post CodeCountry
Previous employer to the one above
Name

First NameLast Name
Job Title
Email
Phone Number

E.g, +44Phone Number
Address

House Number and Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Character reference
Name*

First NameLast Name
Relationship to you*
Email*
Phone Number*

E.g, +44Phone Number
Address

House Number and Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Disclosure Barring Service
Please note that you will be subject to an enhanced DBS check. You are not exempted from the rehabilitation of offender ACTS 2010. This means that all convictions, cautions, reprimands and final warnings on your criminal records must be disclosed.
Do you hold an enhanced DBS certificate/ Police Character Certificate?*
If yes, please enter the certificate number below
You will be required to upload a copy of your DBS certificate
Is your enhanced DBS registered online?
If yes, please enter the online ID number below
Have you ever been convicted by the courts, cautioned, reprimanded or given a warning by the police in the UK or in any other country?*
If yes, please specify
Are you aware of any police enquiries undertaken following allegations made against you, which may affect your suitability for this role?*
If yes, please specify
Are you aware of any pending investigations by the police in which you are involved?*
If yes, please specify
Notice period with existing employer
Please indicate where you found out about the vacancy
Non-Optional Section - Applicant Declaration
- I confirm that the information given above is complete and correct, and that I understand that any incomplete, untrue or misleading information given to the employer will entitle the employer to reject my application, withdraw any employment offer made, or, if I am employed, dismiss me without notice.
- By my signature, I give authority to the employer to contact my GP for further details regarding any of the potential health problems which I have declared above.
- I agree that the employer reserves the right to require me to undergo a medical examination in order to assess my suitability for catering work.
- I do not wish complete the questionnaire, and I do not wish to have a free health assessment. Delete as appropriate (i.e. either strike out 1, 2 and 3, or only 4).
I acknowledge the above declarations

Identifications & Right to work
Kindly upload all required documents as your application will not be completed until all necessary documents are uploaded. Please pay close attention to this section and submit only the documents that apply to you. You can upload from file or take a photo
Do you consent to right to work checks (Includes ECS, EUSS, Share Code & Applicant Right to work)?*
Profile Picture (All Applicants)

You can upload or take a passport photograph using your camera in front of a white background under good lighting.
Cancelof
CV (All Applicants)

Up-to-date copy that covers the whole of your working and educational life till date.
Cancelof
UKVI IELTS Result (Outside the UK)

This is only applicable to candidates applying from abroad
Cancelof
Proof of Identity / Right to Work (UK Residents Only)

British, Bio-metric Residency Card (Front & Back) or Home Office Letter
Cancelof
International Passport (Outside the UK)

This is only applicable to candidates applying from abroad
Cancelof
DBS Certificate (UK Residents only)

Front and back of Certificate required
Cancelof
Police Character Reference / Certificate (Outside the UK)

This is only applicable to candidates applying from abroad
Cancelof
Proof of NI (UK residents Only)

Only applicable to UK residents
Cancelof
Tuberculosis Test Result (Outside the UK Only)

This is only applicable to candidates applying from abroad
Cancelof
Proof of Address 1 (UK Residents Only)

This could be your driving license, payslip, tenancy agreement or a letter from GP, bank statement
Cancelof
Proof of Address 2 (UK Residents Only)

This could be your driving license, payslip, tenancy agreement or a letter from GP, bank statement. Please do not submit one document twice
Cancelof
Training Certificates & Professional Qualifications (All Applicants)

Cancelof
Covid Vaccine Pass/Vaccine Card/CertificateFile Upload

Cancelof

Bank Details
Name on Account
Please enter your full name and title as it appears on your bank account
Account Number
Bank Name
Sort Code
Applicant Declaration - Read before Signing

I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.
I understand that I cannot be offered a post until a satisfactory response has been received with respect to my ISA Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise the organisation to request an ISA Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my ISA Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status.
I acknowledge the above declarations
Date of application*

DayMonthYear
Signature*

Clear

Staff File - Consent to Review

Private and Confidential
Dear staff member,

As Part of our Quality Assurance monitoring by The Council/ CQC, part of this process is to review staff information, including checking that appropriate training and supervision of staff is carried out and in line with GDPR.

Please provide your consent for relevant staff to undertake a review of your staff file.
Location/CQC:
Staff Name*

First NameLast Name
Position*
I hereby authorise relevant staff from Local Authority/ CQC to review my staff file
Signature*

Clear
Date*

DayMonthYear

GDPR Data Sharing Consent Declaration

Private and Confidential
I hereby give my permission for GA Professional Healthcare to share personal information with other service providers in connection with my work, including accessing and sharing my medical, and if applicable, mental health and police records. I understand that GA Professional Healthcare may hold information gathered about me from the various agencies and as such my rights under the Data Protection Act will not be affected.

Statement of Consent:
- I understand that personal information is held about me.
- I have had the opportunity to discuss the implications of sharing or not sharing information about me.
Your consent to share personal information is entirely voluntary and you may withdraw your consent at any time. Should you have any questions about this process, or wish to withdraw your consent please contact
Staff Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear

Consent For Employment Background Check

(Please read before signing)
I hereby authorise GA Professional Healthcare to investigate my background and qualifications and right to work for purposes of knowing whether I am qualified for the position for which I am applying.

I understand that GA Professional Healthcare can use other agencies / companies to assist it in checking such information.

I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately.

I understand that I cannot be offered a post until a satisfactory response has been received with respect to my ISA Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the CRB / DBS.

If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers.

I undertake to inform GA Professional Healthcare immediately if my ISA Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status.
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear

Equality Monitoring Form

Private and Confidential
GA Professional Healthcare collects equality information solely for monitoring purposes to ensure that our policies and procedures are effective. Our Equality Policy commits us to having a workforce that reflects all sections of society – the data you share will be used to monitor and evaluate if these obligations are met or not. GA Professional Healthcare is committed to the principles of fairness, consistency, meritocracy and equality of opportunity. No applicants will be discriminated against regardless of their age, colour, disability, ethnicity, gender or gender identity, race, religion or belief and / or sexual orientation or if you do not wish to complete this form.

The information you enter on this Equality and Diversity monitoring form will be used for monitoring purposes only and will not be used in assessing and or scoring your application or at interview stage. This information is kept fully confidential and accessibility is strictly limited in accordance with the Data Protection Act.
Name*

First NameLast Name
Position Applied For:*
Are you:*
Gender*
If you are undergoing the process of gender reassignment, please tick the box that applies to your future gender.
Media (where did you see the advertisement?)
Do you live and work in a gender other than that assigned at birth?*
What age group do you belong to?*
How would you describe your sexuality?*
Do you consider yourself to have a disability?*
The Equality Act 2010 protects people who are disabled including those with long-term health conditions.
If ‘Yes’ please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

Physical ImpairmentSensory ImpairmentMental Health ConditionLearning Disability / DifficultyLong-standing IllnessOther
Please indicate which ethnic group you consider yourself to belong to?*
Please indicate which religion you consider yourself to belong to?*
Thank you for taking the time to complete this equality monitoring form.

WORKING TIME REGULATIONS EMPLOYEE OPT-OUT AGREEMENT

(This form is also to be completed by Students who wish to work more than 20 hours during holiday periods)
This agreement is between GA Professional Healthcare, the Employer and the Employee
Name of Employee:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
OPT-OUT AGREEMENT

I am aware of The Working Time Regulations 1998, and understand their implications with reference to my Terms & Conditions of Employment.
- The employee understands that they are entitled to have their average week working time limited to 48 hours per week
- The employee agrees that the 48 hours limit shall not apply in their case.
- This agreement applies until it is terminated by the employee in accordance with clause 4/5
- If the employee wishes to terminate this agreement, they must give a notice in writing to the employer within a minimum of 7 days, or a maximum of 3 months.
The Organisation’s Staff Time-keeping Records will confirm my hours worked on a weekly basis. Where these records confirm that I have worked in excess of 48 hours per week, I agree that this 48-hour week limit under The Working Time Regulations, 1998, shall not apply to me.

I understand that I may agree to opt back into the 48-hour week limit at any time, giving the appropriate notice due.
Yes, I wish to opt outNo
Employee Signature

Clear
Date

DayMonthYear
Supervisor/Manager Signature

Clear
Date

DayMonthYear
Should be Empty:

	Yes	No
Giddiness, Fainting attacks, Epilepsy
Stroke, Heart trouble, High blood pressure, Varicose Veins
Mental illness, Anxiety or depression
Recurring Headaches
Skin Trouble
Serious Injury, Serious Operation
Ear trouble / deafness
Serious hay fever, Asthma, recurring heart diseases
Eye trouble / Colour Vision
Recurring stomach trouble, Recurring bowel trouble
Back trouble, muscle/joint trouble
Recurring bladder trouble
Harnia/Joine trouble
Diabetes

	Yes	No
Standing
Working at Heights
Walking
Use of Hands
Climbing Ladders
Stair Climbing
Driving of a Vehicle
Working on Singing

	Yes	No
Have you had any medical problem in the past which has prevented you from working at night?
Are you diabetic?
Are you subject to angina, or other heart problems which may affect your fitness?
Are you suffering from any circulatory problems which affect your work?
Have you had duodenal or stomach ulcers in the past, or under treatment at present?
Have you had any continuing bowel problem, for instance following major surgery?
Do you have any chronic chest problem such as asthma, emphysema or bronchiectasis?
Do you have any disability affecting mobility which will cause difficulties in arranging night work?
Do you have any recurrent or continuing sleep disturbance requiring medical advice?
Are you having specialist care requiring your attendance at hospital clinics for treatment?
Do you have any other health problem which affects your fitness for night work?
Are you taking any medication to a strict timetable?

Staff Application Form

Current or most recent Employer

Employer prior to the one above

Current or most recent Employer

Previous employer to the one above

Character reference

Health Screening Questionnaire

SECTION A

SECTION B

SECTION C

SECTION D

Staff File - Consent to Review

GDPR Data Sharing Consent Declaration

Consent For Employment Background Check

The Working Time Regulations 1998 Health Assessment Questionnaire - Night Workers

Equality Monitoring Form

WORKING TIME REGULATIONS EMPLOYEE OPT-OUT AGREEMENT

	Previous Occupations	Length of Time Employed	Name & Address of Employer
1
2
3
4