Application form

Details entered in this part of the form will be held by our People Services Team.

Position applied for:

Personal Details

*Surname/Family Name

First names

Name in which you are registered with a professional body (if applicable)

Title

I would describe my ethnic origin as:

UK National Insurance No

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Telephone

Mobile Telephone

Email

Do you have an NHS email?

Yes
No

Please enter your NHS email address

Do you have a Smartcard?

Yes
No

Please enter your Smartcard number

Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions after the rehabilitation period set by the Court has elapsed and the convictions become “spent”. During the rehabilitation period, convictions are referred to as “unspent” convictions and must be declared to employers. Before you can be considered for appointment we need to be satisfied about your character and suitability. Procare aims to ensure equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion or belief, disability, sexual orientation and age. Procare undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. If you are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory disclosure from the Disclosure and Barring Service. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment. Anyone applying for a position which involves a regulated activity and certain controlled activity from 12 October 2009 will require an enhanced DBS check and that disclosure will, where appropriate to the role, include information against the Independent Safeguarding Authority barred lists for working with children or working with adults or both.

Are you currently bound over, or do you have any unspent convictions issued by a Court or Court Martial in the UK or any other country?

Yes
No

Please supply details below

Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975

In order to protect certain vulnerable groups within society, there are a number of posts that are exempt from the provisions of the Rehabilitation of Offenders Act 1974. As the post you have applied for falls within this category, it will be exempt from the provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants for such posts are not entitled to withhold any information about convictions or other relevant criminal record information which for other purposes are “spent” under the provisions of the Act. If you are successful with this application, any failure to disclose such information could result in dismissal or disciplinary action. Any information provided will be confidential and will be considered only in relation to posts to which the Order applies. From 12 October 2009 under the terms of the Safeguarding Vulnerable Groups Act (2006), all positions involving regulated and certain controlled activity with children and vulnerable adults and which are carried out frequently, intensively or overnight will require an enhanced DBS check. Where appropriate to the role, the DBS disclosure will include information against the Independent Safeguarding Authority barred lists for working with children and/or vulnerable adults.

Are you currently bound over or have you ever been convicted of any offence by a Court or Court-Martial in the United Kingdom or in any other country?

Yes
No

If YES, please include details of the order binding you over and/or the nature of the offence, the penalty, sentence or order of the Court, and the date and place of the Court hearing. Please note: you do not need to tell us about parking offences.

Has your name ever appeared on the Protection of Children's List or have you ever been referred to the Independent Safeguarding Authority (ISA) for consideration of barring against the Children's List?

Yes
No

Has your name ever appeared on the Protection of Vulnerable Adults List or have you ever been referred to the Independent Safeguarding Authority (ISA) for consideration of barring against the Vulnerable Adults List?

Yes
No

Relationships

If you are related to a director, or have a relationship with a director or employee of an appointing organisation, please state the relationship

APPLICATION FOR EMPLOYMENT

Details entered in this part of the form will be held by the People Services Team.

Education & Professional Qualifications

Include in this section all the relevant qualifications (including GCSE’S, AS and A levels). Please also indicate subjects currently being studied. All qualifications disclosed will be subject to a satisfactory check.

Subject/Qualification

Place of Study

Grade/Result

Start date

Please by Do

End date

Add another?

Yes
No

Subject/Qualification

Place of Study

Grade/Result

Start date

End date

Add another?

Yes
No

Subject/Qualification

Place of Study

Grade/Result

Start date

End date

Add another?

Yes
No

Subject/Qualification

Place of Study

Grade/Result

Start date

End date

Training Courses Attended

Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking.

Course Title

Training Provider

Duration

Date completed

Add another?

Yes
No

Course Title

Training Provider

Duration

Date completed

Membership of Professional Bodies

Include in this section any relevant professional registrations or memberships. If you are registered then please enter the relevant details below; this information will be subject to a satisfactory check.

*Please indicate your Professional Registration status if relevant to this post:

I do not have the relevant UK professional registration status
I have current UK professional registration
UK professional registration required and applied for
UK professional registration required but not yet applied for
I am a graduate
I am a student
Not required for this post

If professional registration is not required then go to Employment History.

If you are registered then please enter the relevant details below:

Professional Body

Membership or Registration type

Membership/Registration PIN

Expiry/Renewal Date

If you are applying for a post that requires professional registration you are required to provide the following information:

Are you currently the subject of a fitness to practise investigation or proceedings by a licensing or regulatory body in the UK or in any other country?

Yes
No

Have you been removed from the register or have conditions been made on your registration by a fitness to practise committee or the licensing or regulatory body in the UK or in any other country?

Yes
No

If applicable, please provide details of any conditions/restrictions you may have.

Employment History

Please record below the details of your current or most recent employers

Do you have a current employer?

Yes
No

Employer name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job title

From Date

Reason for leaving (if applicable)

Do you have a previous employer?

Yes
No

Employer name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job title

From Date

To Date

Reason for leaving (if applicable)

Do you have another previous employer?

Yes
No

Previous Employer 2

Employer name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job title

From Date

To Date

Reason for leaving (if applicable)

Do you have another previous employer?

Yes
No

Previous Employer 3

Employer name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job title

From Date

To Date

Reason for leaving (if applicable)

Do you have another previous employer?

Yes
No

Previous Employer 4

Employer name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job title

From Date

To Date

Reason for leaving (if applicable)

Do you have another previous employer?

Yes
No

Previous Employer 5

Employer name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job title

From Date

To Date

Reason for leaving (if applicable)

Do you have another previous employer?

Yes
No

Previous Employer 6

Employer name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job title

From Date

To Date

Reason for leaving (if applicable)

Please add additional employers/information as required

If you have any gaps within your employment or education history, please state below the dates and reason for any gaps.

References

Please state the names and contact details of the people who have agreed to supply references covering a minimum of 3 years employment/education. If you are or have been employed, these should include your two most recent employers, your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. If you are a student please provide contact details of a teacher at your school, college or university. If you have not been in employment for a considerable amount of time but have had previous employment, then you should seek one reference from your last known employer and a personal reference from a person of some standing within your community i.e. doctor, solicitor, MP etc. Where it is not possible to obtain any employer reference at all then please obtain two personal references. Where no personal reference can be obtained then references should be sought from personal acquaintances not related to or involved in any financial arrangement with you. If you have undergone training to return to work then the academic institution should be contacted. Personal references such as friends and relatives are not acceptable unless stated previously. Please note, all reference requests will be sought through your line manager or other relevant department manager and your employment history will be verified through the organisation’s recruitment function. Please ensure that you provide full contact details.

Employer / Education Institution Name

Reference Name

First

Last

Title

Job Title

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone

Email

Relationship

Dates of employment/education this reference covers

Reference 2

Employer / Education Institution Name

Reference Name

First

Last

Title

Job Title

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone

Email

Relationship

Dates of employment/education this reference covers

Please give further referee details if those given above do not cover the last 3 years of your employment/education history.

Are you happy for us to contact your referees?

Yes
No

General Data Protection Regulation

Procare is committed to protecting the privacy and security of your personal information. Please see our privacy notice which describes how we collect and use personal information about you during and after your working relationship with us, in accordance with the UK General Data Protection Regulation (UK GDPR). It applies to all employees, workers and contractors.

*DECLARATION

The information in this form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. Where applicable, I consent that the organisation can seek clarification regarding professional registration details.

I agree to the above declaration

Signature

Name

First

Last

Date