Agency Staff Application Form

Application Form
Which job are you applying for?*
Title*
First Name*
Middle Name(s)
Last Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth

MonthDayYear
Phone Number

Area CodePhone Number
Landline Number

Area CodePhone Number
Email*
National Insurance Number*
NMC PIN Number
**Nurses only**
Do you hold a DBS Certificate which has been issued in the last 12 Months
DBS Reference Number
DBS Reference Number
Do you consent to Sync Alliance undertaking a DBS check?*

YesNo
Do you have any convictions, cautions, reprimands or final warnings which are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)?*

YesNo
Are you eligible to work in the UK?*

YesNo
Do you consent to Sync Alliance Healthcare undertaking 'Right to Work' checks? (if applicable)*

YesNo
Do you hold a FULL UK Driving Licence
How many times per week can you work?
Select preferred shifts
Please select relevant clinical areas that you have experience in*

Elderly CareLearning DisabilityPersonality DisordersChild and AdolescentEating DisordersAcute Mental HealthGeneral NursingDrug and AlcoholDomiciliary CareOther
Please select your work availability
Upload Up-To-Date CV*

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Briefly, in your own words, describe why you are an ideal candidate for this position
Next of kin*
SEX
Marital Status
Sexuality
Which best describes your Ethnicity?
“Ethnic Origin” refers to a racial group defined by the Race Relations Act 1976 as a group of persons described by reference to colour, race, nationality or ethnic origin.
Do you have any mental or physical disabilityor illness (currently or recurring) which is relevant to the post for which youare applying?
Please provide details of mental or physical disability or illness *
What adjustments (if any) need to be made to the working environment to accommodate your disability?
Please give details of all absences from work in the last 12 months, except holidays
Please give details of any illness/accidents/injuries in the last 2 years
Education
College / higher education*
Qualifications gained*
University
Qualifications gained
Previous Employment

You must include your current and previous employer details with start and end dates
Employer 1*
Reasons for leaving employer 1*
Employer 2*
Reasons for leaving employer 2*
Employer 3
Reasons for leaving employer 3
References
Please Provide Professional References For The Last 3 years.

**please ensure you provide professional/company email addresses!
Do you consent to Sync Alliance contacting your references?*

YesNo
REFERENCE 1*
REFERENCE 2*
REFERENCE 3*
Documents Required
Please select which documents you can upload now.
Please upload the above documents

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Please upload Proof of Right to work*

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You may upload multiple files, Passport/Visa Card Cancelof
Upload Two Proof of Address Documents

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Please upload a copy of your DBS Certificate

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Please upload passport size/type Picture

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Please upload a photo for ID purposes, filing, and other. Cancelof
Training Certificates
Please upload copies of ALL relevant training certificates you will have completed within the last 12 months.
Please upload copies of training certificate

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DECLARATIONS
I confirm that the information I have provided is correct and current and that nothing relevant has been omitted. Checking the box above is equivalent to a handwritten signature. Providing false information is an offence and could result in the application being rejected or summary dismissal if you are selected.*

Yes
Do you consent to Sync Alliance Healthcare holding your data for the purposes of finding you employment?

Yes
Insert Signature*
Insert Full Name (IN BLOCK CAPITALS)*
Date Signed*

MonthDayYear
Date

Should be Empty:

Application Form

Education

Previous Employment

References

Documents Required

Training Certificates