Shortlisting will be based on the information gathered from the form, in conjunction with the job description.

Consent & Disclaimer

I confirm that the information provide above is accurate and that I have obtained permission from the person listed above to share their contact details.

Current Address

We require details of the last 5 years of address history for Access NI purposes.

Please tick the box in accordance with the level of expertise as indicated below: 

1. Familiar with the procedure and can perform
2. Familiar with the procedure but need supervision
3. Understand the theory of procedure, but never task 
4. No knowledge of the procedure

I confirm that this is a true and accurate representation of my skills and experience.

Please list your employment history starting with your most recent job. Including all positions held since leaving full-time education. 

Please upload your up-to-date CV, covering letter, and any supporting documentation .

Disciplinary & Investigations disclosure

Please give details of two referees, one of whom must be your current or most recent manager or school/ college.  References from family or friends are not acceptable.  Personal emails are also not accepted.

Reference Disclaimer
By completing this section, you acknowledge and agree that Kingdom Healthcare will contact the referees you have provided for the purpose of obtaining references regarding your employment history, qualifications, and suitability for the position applied for. You understand that these references will be verified for accuracy and may form part of the basis for employment decisions. By submitting this application, you consent to the collection, processing, and retention of reference information in accordance with applicable data protection legislation, including the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.

The information on the application form will be held and processed in accordance with the requirements of the Data Protection Act 1998.

We are required to hold personal information on staff e.g. National Insurance Number, Address, Qualifications. From time to time, we may be required to release elements of this information when placing you in assignments; please be assured that we would only disclose information that is necessary. We would therefore be grateful if you would complete and sign the declaration below. If you have any concerns about this or want to discuss it further, please contact your branch manager.

 I understand that the information is being use to: 

• Process my application for employment:
• Form the basis of a computerised record on the recruitment system for processing and monitoring purposes.
• Form the basis of a manual job file with other application forms, and will be used for processing
• If appointed, form the basis of a manual and computerised employment record.

I declare that the information provided on this form is true and complete to the best of my knowledge and belief.  I understand that any false or omitted information may result in the withdrawal of any conditional offer made, or dismissal or other disciplinary action if I am appointed.

Please note:

All information received will be dealt with in confidence, consistent with our commitment to safeguarding vulnerable adults.

We are committed to safeguarding vulnerable adults and to ensuring equal opportunities for all applicants.  Information about criminal convictions is requested to assist the selection process and will be taken into account only when the conviction is considered materially relevant to the position applied for.

You have applied for a position that is defined as Regulated Activity under the Safeguarding Vulnerable Groups (NI) Order 2007.  It also falls within the definition of an ‘excepted’ position under the Rehabilitation of Offenders (Exceptions) Order (NI) 1979.  This means that you must tell us about all offences and convictions, including those considered ‘spent’.

If you have received a formal caution or are currently facing prosecution for a criminal offence, you should also bring this to our attention given the “excepted’ nature of the role.  If you leave anything out it may affect your application.

This information will be verified through an AccessNI Enhanced Disclosure Check (EDC) if you are considered to be the preferred candidate and are being offered the position. The EDC will tell us if you have a criminal record or if your name has been included on the Children’s Barred List and/or Adult’s Barred List.  It is to make sure that individuals who are considered a risk to vulnerable adults and/or children are not appointed.  Please note that successful candidates will have to pay a non-refundable administration fee, which is currently £32, for the completion of the EDC conducted under our vetting process.  Details regarding payment will be included in any formal written offer of employment.

The information received will be treated confidentially and will be assessed alongside normal selection criteria to determine suitability for the position.  A separate meeting will be held with you if clarification is required to discuss any issues around your disclosure before a final decision is reached.  After the decision has been made the information will be destroyed.

A copy of the Access NI Code of Practice and Kingdom Healthcare’s policy on Recruitment of Ex-Offenders and Use of Access NI Disclosure Information Policy, which includes storage, handling, retention and disposal of disclosed information, will be made available to all applicants on demand.

Please complete the attached form and return it with your application.  The form also asks you to give your written consent to the Access NI EDC and agree to further enquiries being made relevant to the declaration, which will only be obtained if you are the preferred candidate.  If you do not consent, we will not accept you{positionApplied}r application.

Applicants can also submit a separate statement of disclosure if they wish.  This may include details such as particular circumstances around the conviction(s); how the circumstances may have changed; and what has been learned from the experience. Applicants can contact the Northern Ireland Association for the Care and Rehabilitation of Offenders (NIACRO) for more information.

Rehabilitation of Offenders Act 1974 & Criminal Records

By virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986, the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 DO NOT APPLY to any employment which is concerned with the provision of health services. You should therefore list all offences on a separate sheet, even if you believe them to be ‘spent’ or ‘out of date’ for some other reason. Kingdom Healthcare have a policy on ‘The recruitment of ex- offenders.’ You are welcome to view this policy at any time during the course of your employment with Kingdom Healthcare. Having a criminal record will not necessarily prevent an applicant from working with us. This will depend on the nature of the position, the circumstances and the background of offences. All workers are required to advise Kingdom Healthcare if they incur a conviction or caution during the course of their employment.

Please tick the appropriate response.

Declaration of Abuse Investigations(s)

DECLARATION AND CONSENT

I declare that the information I have given is complete and accurate.  I understand that I will be asked to complete an AccessNI Disclosure Certificate Application Form if I am considered to be the preferred candidate, and I consent to the Enhanced Disclosure Check being made, and I agree to enquiries relevant to the declaration.