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HERITAGE STAFFING SERVICES LTD

APPLICATION FORM

APPLICANT’S NAME: ……………………………………………….

POSITION APPLIED: ………………………………………………….

DATE OF APPLICATION: ……………………………………………

AUTHORISED BY

MANAGEMENT: ………………………………………………………….

START DATE: ………………………………………………………………..

16 – 20, Suites D-F, Bush House, Bush Fair Shopping Centre, Harlow, Essex CM18 6NS

Tel: 01279 944392 Mob: 07341821891

Email: [email protected] web: www.heritagestaffing.co.uk

Company Reg No: 8963028

Staffing solution provider
Application Form- Confidential

The information supplied on this application form will be used to evaluate your suitability for employment at Heritage Staffing Services Limited. Please read
the guidance notes before completing the forms. Once completed, please return the forms to us. If applying by email, please remember to quote the relevant
job reference in the subject line of your email.

Position applied for: ____________________________________________________ Post reference no.: ___________________________________

Personal information
Last name: ________________________________________________________ Title (Please specify) e.g. Ms/Mr ____________________________

First name(s): ______________________________________________________ National Insurance number: ______________________________

Previous surnames(s) (if applicable): _____________________________________ Do you require a work permit to enable you to work in the UK?
(Yes or no) ________________

Address for correspondence: __________________________________________ Daytime telephone number: _______________________________

__________________________________________________________________ Evening telephone number: _______________________________

__________________________________________________________________ Mobile number: ________________________________________

__________________________________________ Postcode________________ Email: ________________________________________________

Please answer the following question if the job/person profile for the job requires this.

Do you hold a current full driving license? Yes No

If yes is it a clean driving license? Yes No If no please give details ___________________

Qualification and Training

Date (From / To) Secondary School/ Qualification Subject Grade Obtained
college/
university/training
organization

Next of Kin Relationship to The Applicant Day Phone Evening Phone

Membership of Professional Bodies (Nursing and Midwifery council, General Social Care Council or Other)

Name: _____________________________________________ Membership/ Status

_________________________________________
Renewal Date ___________________________________________________ Number
__________________________________________
Employment Experience
Please give details of your present or most recent employment/voluntary work first and work backwards. Include all periods of
unemployment; travel etc, in the space provided so there are no gaps in the record. (If you have additional previous employment, please
give details on a separate sheet using the same format).

Date: from/to Employer’s name and Job titles and brief Current salary or final
(month/year address and nature of description of duties salary (for post only) and
business reason for leaving

Gaps in your employer- Please provide information of any gaps in employment

(Verification of employment gaps will be required if an offer employment is made)
From (Month/Year) To (month/Year) Reason
References
Please ensure that you give a minimum of two references which cover at least the last five years of your employment. The first of your
references must be your present employer and your relevant line manager. If you are unemployed, this should be your last employer, or if
this is your first job, your head-teacher or college tutor. Please note that Heritage Staffing Services Ltd reserves the right to take up
references in respect of any previous employment paid or unpaid, without further notification to you.* You may also provide the name of
a personal referee as well as your employment references if you wish.

Current employer: Previous employer/Character Reference:

Name: ______________________________________________ Name: ____________________________________________

Job title: _______________________________________________ Job title: __________________________________________

Organization address (in full): ______________________________ Organization address (in full): ________________________

_______________________________________________________ _________________________________________________

_____________________________Postcode_______________ ________________________________Postcode__________

Tel No.: ____________________________Fax No.: _____________ Tel No.: __________________________Fax No.: __________

Email: ___________________________________________________ Email: _____________________________________________

In what capacity do you know them? _______________________ In what capacity do you know them?
____________________

Can we contact your current employer prior to any conditional offer of employment? Yes No

*** Please note that it is Heritage Staffing Services Ltd’s policy to obtain references prior to interview for any post in a residential
establishment. For all posts, we will ask your referees for comments on your suitability for the post and for employment referees request
details on attendance, sickness levels and salary.

Notice Period If appointed how soon you could join us: _________________________

Disability Heritage Staffing Services Ltd has a policy of interviewing applicants who have a disability and who meet the essential short-
listing criteria. In order to ensure that this happens, please complete the following:

a) The Equality Act 2010 defines disability as' a physical or mental impairment which has a substantial and long-term adverse
effect on the ability to carry out normal day-to-day activities. Do you consider yourself to have or have had a disability?
Yes No If yes please give details: ______________________________________________________________

b) If the answer to the above is yes, are there any reasonable adjustments that need to be made, should you progress beyond this
stage?

Yes No If yes please give details: ________________________________________________________________

Relevant Experience

Please tell us how your experience, skills and qualifications meet the requirements of the person and job profiles. Please focus your
response on the abilities and/or competencies required for the role giving evidence of your experience to date (maximum of 2 A4 sheets).
The information you provide will be the basis for shortlisting and you may find it useful to refer to the guidance notes attached before
completing this section. (Please use continuation sheet)
 Bank/ Building Society Details
Surname:

Forenames:

Branch:

Payroll: Private/Domestic Payroll No:

TO BE COMPLETED BY EMPLOYEE

I authorized Heritage Staffing Services to pay my weekly earnings direct into the Bank/Building society Account whose details follow.

I will notify Heritage Staffing Services in writing of any change to these details

Building Society Roll No: (if applicable)

Bank Name: (if a Building Society Account please give the Society’s Bank details)

Bank Branch:
Sort Code:
Account Holder’s Name:
Account No:

Signed: Date:
Name Printed:

REHABILITATION OF OFFENDERS

Applicant Declaration

Because of the nature of the work for which you are applying, the provisions of Section 4(2) of the Rehabilitation of Offenders Act (1974) do
not apply by virtue of the Rehabilitation of Offenders Act (1974) (exceptions) Order 1975. Applicants are therefore required to give
information about convictions, which for other purposes are '‘pent’ under the provisions of the Act. Any information given will be completely
confidential and will be considered only in relation for positions to which the Order applies.

HAVE YOU AT ANY TIME BEEN CONVICTED OF AN OFFENCE? (Y/N) IF YES, PLEASE GIVE DETAILS BELOW: -

I declare that the information given above is, to the best of my knowledge, true, I am permitted to work in the UK. I have read, understood and
agree to the conditions of work for temporary nurses and carers, of which I have been given a copy. I understand that my registration is
subject to the receipt of at least two satisfactory references and a satisfactory result after checking with the Department of Health and/or
Police records.

I undertake to inform Heritage Staffing Services should I be convicted of an offence in the future. I acknowledge that this information may
form the basis of a computerized personnel system to which I will have access as determined by the Data Protection Act 1984. I agree to
respect the confidentiality of Patients and any other information I may have access to all times.

Your registration with Heritage Staffing Services can be terminated at any time following unsatisfactory work reports.

PROFESSIONAL INDEMNITY (MALPRACTICE) INSURANCE FOR QUALIFIED NURSES MIDWIVES, NURSING AUXILIARIES AND CARERS.
Contribution to the scheme is compulsory and a small charge (currently £2.38p per week) is automatically deducted from your payment

Signed: Date:

Criminal Records, Disqualification & Declaration

Please refer to covering letter before completing section B, C or D below
Section A- All applicants
Are you subject to any current outstanding disciplinary action or legal proceedings? Yes No

If yes, please give details:

_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

Section B - General posts

Criminal convictions

Have you ever been convicted of a criminal offence (‘unspent’ only)?

Yes No

If yes, please give us details of all offences, penalties and dates on the page
marked Criminal Record/Disqualification/Other in this application form.
______________________________________________________________________________________________________________

Section C- Posts working with children or vulnerable adults

Criminal record Yes No

Have you ever been convicted of a criminal offence or cautioned?
Reprimanded or given a final warning by the police (‘spent’ or ‘unspent’)?

If yes, please give details of all offences, penalties and dates on the page
Marked Criminal Record/Disqualification/Other in this application form.

Regulatory body sanctions

Are you subject to any sanctions imposed by a regulatory body, Yes No
eg GSCC, NISCC, SCCC, CCW, GTC?

If yes, please give details on the page marked Criminal Record/

Disqualification/Other in this application form.

Disqualification from working with children or vulnerable adults Yes No

Are you disqualified from working with children or vulnerable adults?
________________________________________________________________________________________________________________
Section D- Enhanced Disclosures only
Are you aware of any police enquiries undertaken following allegations Yes No
made against you that may have a bearing on your suitability for the post?

If yes, please give details on the page marked Criminal Record/ Disqualification/Other in this application form.

Declaration- To be completed by all applicants

I confirm that the information I have given is correct and complete and that any false statements or omissions may render me liable to
dismissal without notice or in some instances, referral to the police.

I understand and agree that data contained in the application form will be used and processed for recruitment purposes.
I also understand and agree that should I become an employee, the information will also be used for employment related purposes.
I agree to Heritage Staffing Services Ltd’s holding and processing this information

Signed: ………………………………………… Date: ………………….

Criminal Records/ Disqualification/ Other

Details of Declaration of Criminal Convictions (Please give details below):
_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________
 Declaration of Health (Ref 5U)

Name:
Maiden Name:
Home Address:
Postcode: Phone:
Please answer the following questions by ticking the appropriate YES/4O box. If the answer to any questions is YES, then give details in the space provided or on the back of this form. It is your
responsibility to inform us immediately if any of the following information changes.

Have you ever had in your life, including childhood, any of the following?

Description of illness Yes No Details/Dates

1. Cardiac/Vascular illness

2. Eye Disease/ Inquiry or Defect of Vision not

Corrected by Lenses
3. Asthma
4. Tuberculosis
5. Diabetes

6. Epilepsy, Frequent Fainting Attacks

7. Chicken Pox
8. Any Degree of hearing loss
9. Hepatitis
10. Back Pain, Sciatica
11. Do you have any deformities, which effect movements?
12. Are you receiving any medication from a doctor?
13. Have you ever been treated for any other
serious illness/operation?
14. Are you registered a disabled person?
15. Mental Illness
16. I believe that I am medically fit to carry out
the duties of the position I have applied for
17. Are there any reasonable adjustments that an
employer should make to enable you to work?
Please give details of last immunization or vaccination for:

Tuberculosis (we will require a statement of evidence regarding TB immunity i.e. Heaf / Mantoux status)
Rubella (German Measles) /Anti-body level:
Poliomyelitis /Anti-body level:
Varicella /Antibody level:
Tetanus /Anti-body level:
Hepatitis B /Anti-body level:
Any Other
Additional Information General Practitioner’s
Name:
Address or Occupational health Department:
I declare that all the forgoing statements are true and complete to the best of my knowledge and belief.
I hereby give Heritage Staffing Services permission to contact my general Practitioner to obtain further information should it be required.

Signed: Date:

Availability Form
Type of work Hours of work
Home care [ ] Hospital [ ] Residential [ ]
Domestic [ ] Cook [ ] Kitchen Assistant [ ] FULL TIME [ ] PART TIME [ ]
0
Hours Available (please tick as applicable)
Morning (7am – 2.30pm) Afternoon (2pm – 9.30pm) Night/Sleep-In (9.30pm – 7am)
Monday to Sunday [ ] Monday to Sunday [ ] Monday to Sunday [ ]