Recruitment - New Applicant Form

Recruitment - New Applicant Form

Salus NE Ltd
Personal Information
Title*
Forename*
Your Legal Forename
Middle Name
Your Legal Middle Name
Surname*
Your Legal Surname
Preferred Name
Gender*
Date of Birth*

DayMonthYear
Home Address*

Address Line 1

Address Line 2

CityCounty

Post Code
Phone Number*
Email Address*
Emergency Contact Information
Emergency Contact Forename*
Emergency Contact Surname*
Emergency Contact Relation*
Emergency Contact Phone*
Right To Work
Are You A United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National?*

YesNo
National Insurance Number*
UTR Number
Do You Have Any Of The Following?*

PassportDrivers LicenceBirth CertificateProof of National Insurance NumberNone of The Above
Upload Passport*

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Full Passport, All 4 Corners In Photo Cancelof
Upload Drivers Licence*

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Both Front & Back, All 4 Corners In Photo Cancelof
Upload Birth Certificate*

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Full Document, All 4 Corners In Photo Cancelof
Upload National Insurance*

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Full Document, All 4 Corners In Photo Cancelof
Please Select The Category That Relates To Your Current Immigration Status*
Immigration Status - Other*
Visa Number*
Visa Start Date*

DayMonthYear
Date
Visa End Date*

DayMonthYear
Date
Does Your Visa Have A Condition Restricting Employment or Occupation In The United Kingdom (UK)?*
If Yes, Please Provide Details
Upload Visa*

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Role Applying For
What Role Are You Applying For?*
Salary Desired
Have You Applied Before*

YesNo
Have You Worked For Us Before*

YesNo
Clinical Qualifications & Skills
Clinical Qualification Held*
Qualification Expiry Date*
Please Put N/A If No Expiry Date
Are You A Healthcare Student?*
NMC / HCPC / GMC Pin
Do You Hold A Safe Administration of Life Saving Medication Level 3 Certificate?*

YesNo
Do You Hold An In-Date Life Support Certificate (BLS / ILS / ALS)?*

YesNo
Do You Hold A Administration of Penthrox Certificate?*

YesNo
Do You Hold A Teaching Qualification?*

YesNo
Upload Qualification Certificates*

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Driving
Do You Hold A Full Category B Driving Licence?*

YesNo
Are You 21 Years Of Age or Older, And Driven For More Than 2 Years (For Insurance Purposes)?*

YesNo
Is Your Licence Restricted To Automatic Vehicles Only?*

YesNo
Do You Hold A C1 Driving Licence?*

YesNo
How Many Points Do You Have On Your Licence?*
Have You Been Convicted Of A Driving Offence Within The Last 5 Years?*

YesNo
Please Provide Full Details Of The Conviction*
Do You Hold A CERAD Level 3 Certificate or Equivalent?*

YesNo
Upload CERAD or Equivalent Certificate*

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Education and Employment History

Education History*

	Institution Name	Date From	Date To	Grade Achieved
English Language GCSE
Maths GCSE
Science GCSE

Further Education History

	Institution Name	Course Name	Date From	Date To	Grade Achieved
College
University

Employment History*

	Employer	Job Role	Start Date	Leave Date	Reason For Leaving
Current Employment
Previous Employment 1
Previous Employment 2

Reference 1 Information
Reference 1 Forename*
Reference 1 Surname*
Reference 1 Phone Number*
Reference 1 Email Address*
Reference 1 Relationship*
Reference 1 Years Acquainted*
Reference 2 Information
Reference 2 Forename*
Reference 2 Surname*
Reference 2 Phone Number*
Reference 2 Email Address*
Reference 2 Relationship*
Reference 2 Years Acquainted*
Enhanced DBS
Do You Hold An Enhanced DBS Certificate?*
You will NOT be able to carry out any work with us until you hold an Enhanced DBS Certificate. This will be arranged by Salus NE, at your own cost.
Is This Certificate On The Update Service?*
You are required to be registered to the DBS Update Service. If you are not registered to this service, a new Enhanced DBS Certificate will be required. This will be arranged by Salus NE, at your own cost.
DBS Number*
Issue Date*
Upload DBS Certificate*

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Criminal Convictions, Cautions, Reprimands, and Warnings
Do you have any unspent criminal convictions, cautions, reprimands, or final warnings?*

YesNo
Have you ever been convicted of a criminal offence (including spent convictions), been cautioned, reprimanded, or received a final warning that is not protected under the Rehabilitation of Offenders Act 1974 (Exceptions Order 1975) as amended in 2013 and 2020?*

YesNo
Have you ever been barred from working with children or vulnerable adults under the DBS barred list?*

YesNo
Are you currently under investigation, or have you been subject to any investigation, disciplinary hearing, or referral to a professional body (e.g. HCPC, NMC, GMC,)?*

YesNo
Have you ever been subject to any safeguarding concern, allegation, or complaint, whether founded or not?*

YesNo
Are you currently subject to any bail conditions, pending prosecution, or court proceedings*

YesNo
If you answered 'Yes' to any of the above, please provide further details below*
Uniform Sizes
Polo Shirt Size*
Jacket Size*
Trouser Size*
Payment Details

All staff employed at Salus NE (Salus Medical) work on a self employed basis. All staff are responsible for paying their own taxes and other associated costs. You will be required to sign a self employed acceptance form before any work is completed.
Name On Account*
Account Number
Sort Code*
Supporting Documents
Upload CV*

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Upload Cover Letter

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Recruitment Monitoring
What Is Your Age Group?*
What Is Your Gender?*
Gender - Other*
Marital Status*
Sexual Orientation*
Sexual Orientation - Other*
Ethnic Origin*
According To The Definition of Disability, Do You Consider Yourself To Have A Disability?*
Please Identify The Category Which Applies To You*

Physical ImpairmentSensory ImpairmentMental Health ConditionLearning Disability / ConditionLong Standing IllnessOther
What Is The Effect or Impact Of Your Disability or Health Condition On Your Ability To Give Your Best At Work?*
Are There Any Reasonable Adjustments We Could Make To Help Remove Physical Barriers or Provide Extra Support To You During Your Application?*
Are You A Member Of The Armed Forces Community*
Where Did You See This Vacancy Advertised?*
Vacancy Advertised - Other*
Employee Name (Referred By)*
Application Submission
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employement may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.
Signature*

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Recruitment - New Applicant Form

Personal Information

Emergency Contact Information

Right To Work

Role Applying For

Clinical Qualifications & Skills

Driving

Education and Employment History

Reference 1 Information

Reference 2 Information

Enhanced DBS

Criminal Convictions, Cautions, Reprimands, and Warnings

Uniform Sizes

Payment Details

Supporting Documents

Recruitment Monitoring

Application Submission