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Personal Details
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Step
1
of 6
Job title you are applying for
*
Registered Nurse
Care Assistant
Support Worker
NMC PIN
*
Only if you are a registered nurse
Title
Mr
Mrs
Ms
Miss
Name
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First
Middle
Last
Date of birth
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Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Nationality
*
United Kingdom of Great Britain and Northern Ireland
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Email
*
Phone number
*
National Insurance Number
*
Do you hold a full & valid driving license for the UK?
*
Yes
No
Are you eligible to work in the UK?
*
Yes
No
Please describe your eligibility to work in the UK. Include what applies to you: settlement status details, BRP number, visa etc.
*
Next
Employment History
*
Briefly detail your employment history within the past 5 years, starting with the most recent. Please include the dates, FROM/TO.
Training and Education
*
Was your mandatory training - for example Moving & Handling, Infection control, Safeguarding, Medication administration (RNs only) completed within the last year? Briefly outline any qualifications as well as professional & vocational training that you feel are relevant to this job.
Mandatory Training
COSHH
Diversity, Equality and Inclusion
Food Hygiene
Health and Safety
Infection Prevention and Control
Safeguarding of Vulnerable Adults
Safeguarding of Children
Moving and Handling
First Aid
GDPR
Basic Life Support
Fire Safety
Please tick if you have completed the above training within the last 12 months. Please enclose copies of your training certificates.
Upload Certificates
Click or drag files to this area to upload.
You can upload up to 12 files.
DBS status. Have you subscribed for the DBS Update Service? Please select.
*
No
Yes
If you selected "Yes", please enter the number of the DBS certificate you subscribe with. Please note this is the DBS certificate number, not your subscription number.
Previous Convictions
*
Please give details of any convictions in this country or abroad you currently or have previously had. If none, please write the word “NONE” in this box. Please be aware that it is an offence to withhold this information.
References
*
Please give details of two people that would be prepared to give you a reference. One must be from a current/previous employer; the other should be a character reference, from someone other than a family member. Any offer of employment will be subject to satisfactory references. By entering their. details here, you give Lita Healthcare Ltd. permission to contact these people. Please include Name, Position, Organisation, Address, Email and Phone Number.
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Next
Health and Safety - Do you have a disability of any kind that may affect your work? Please select.
*
Yes
No
If you selected "Yes", please give details.
Working Preferences
*
Day Shifts
Night Shifts
Weekdays
Weekends
How many days/nights per week?
*
One
Two
Three
Four
Flexible
How would you like to be paid?
*
PAYE
Direct through UTR or company (Ltd)
Name of Bank/Building Society:
*
Account Name:
*
Account No:
*
Sort Code:
*
Online data - we keep a lot of your records securely online. In addition, clients may ask that these are uploaded and shared online with their own client base (e.g. nursing & care homes), prior to the commencement of your first shift with them. Do you authorize that these details can be shared with them online?
*
Yes
No
Working time regulations - the maximum working week is currently limited to 48 hours. As you are under no obligation to accept any work offered, you will not be compelled to work more than 48 hours per week. However, you may choose to do so. Please select.
*
I DO wish to work more than 48 hours per week
I DO NOT wish to work more than 48 hours per week
Previous
Next
Data Protection. Our records, including any copies of documents supplied are kept securely in line with GDPR regulations. You understand & give permission for these to be made available from time to time to authorized personnel or inspectors, Home Office Immigration Check. If applicable, you understand & give permission for Lita Healthcare Ltd. to contact the appropriate authority in order to verify your current immigration status. Please tick.
*
Yes
Upload 1 (one) Category A supportive documents: • Current and valid UK Passport • UK driving license photo card • UK Original Birth Certificate • A UK biometric residence permit card.
*
Click or drag a file to this area to upload.
Upload 2 (two) Category B supportive documents: • A Bank or Building Society statement - less than 3 month old • Utility Bill less than 3 month old • A Credit Card statement • A Council Tax statement • A mortgage statement • A letter from: HMRC, Department of Work and Pensions, Jobcentre Plus or any other employment service •A P45 or P60 statement, a pension or endowment statement or ISA statement.
*
Click or drag files to this area to upload.
You can upload up to 2 files.
Upload a Passport Style photograph. It must be clear, full face, no hats and against a white background.
*
Click or drag a file to this area to upload.
Upload your CV
*
Click or drag a file to this area to upload.
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Next
Hep B
*
Yes
No
TB
*
Yes
No
Varicella
*
Yes
No
Measles
*
Yes
No
Rubella
*
Yes
No
Hep C
*
No Proof
Negative
Positive
Hep B Antigen
*
No Proof
Negative
Positive
HIV
*
No Proof
Negative
Positive
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HEALTH AND SAFETY
*
Each agency worker has a responsibility at the start of their first shift to become familiar with the Client’s general policies including, without limitation, those relating to Emergency Call Procedures, the Hot Spot Mechanism for alerting security staff that an individual is in trouble, Fire Policy and the Violent Episode Policy.
Declaration
*
I confirm that I have read and understood the above and confirm my answers to be accurate and correct. Additionally, I understand that it is my responsibility to update Lita Healthcare Ltd. in the event any of these details change in the future. Any job offer made to me is based on a zero-hours contract with no guarantee of work or working hours. Any job offer made to me is subject to satisfactory references being obtained from the individuals offered above. I give permission for Lita Healthcare Ltd. to contact the referees given. Upon acceptance, if I do not subscribe to the DBS Update Service, Lita Healthcare Ltd. will arrange a Disclosure and Barring Service (DBS) check now, and at intervals thereafter. I also understand that Lita Healthcare Ltd. may contact the Home Office/UK immigration in order to verify my eligibility to work in the UK. If information given on this application form is found to be false it may result in disciplinary action, or dismissal.
Phone
Submit