Yr(s) / Mth(s)



CANDIDATE APPLICATION FORMHow Did You Hear About Us:Preferred Location Of Work:Employment Sought:FULL TIME ? PART- TIME ? TEMPORARY ? DAY WORK ? NIGHT WORK ?Your Current Job Title:NMC No:HCPC No:First Name(s):Surname:Title: Mr/ Mrs/ Ms / MissMaritalStatus:Date of Birth:Current Address:Post code:Mobile No.Home Phone:Email Address:National Insurance No:Next of Kin:(in case of emergency)IMPORTANT INFORMATION – PLEASE COMPLETEName:Contact Number(s):Relationship:Positions Of Interest:Uniform Size:Nationality:Do you have a current driving licence?Yes ? / No ?Do you have access to a vehicle?Yes ? / No ?Are you currently employed?Name of your current employer?Do you have any other commitment(s) which might limit your working hours? If yes, please state:1993901270003914140234315Yr(s) / Mth(s)Yr(s) / Mth(s)0 - 6Months6 - 12Months1 - 2Years2 +YearsMidwiferyMinor InjuriesMinor SurgeryNeonatalNeurologyNICUNurse Led DiabetesNurse PractitionerNurse PrescribingNursing homeOccupational health ExperiencedOccupational health TrainedODP/ODAOphthalmologyOrthopaedicsOut PatientsPaediatricPalliative CarePICU ExperiencedPICU TrainedPractice Nurse ExperiencedPractice Nurse TrainedPrisonsRadiologyRecoveryRenalResidential HomesSCBU ExperienceSCBU TrainedSchool NurseScrubStoma CareSubstance MisuseSurgicalTermination ClinicTheatreUrologyVascular SurgeryWell Man ClinicWell Woman Clinic00Yr(s) / Mth(s)Yr(s) / Mth(s)0 - 6Months6 - 12Months1 - 2Years2 +YearsMidwiferyMinor InjuriesMinor SurgeryNeonatalNeurologyNICUNurse Led DiabetesNurse PractitionerNurse PrescribingNursing homeOccupational health ExperiencedOccupational health TrainedODP/ODAOphthalmologyOrthopaedicsOut PatientsPaediatricPalliative CarePICU ExperiencedPICU TrainedPractice Nurse ExperiencedPractice Nurse TrainedPrisonsRadiologyRecoveryRenalResidential HomesSCBU ExperienceSCBU TrainedSchool NurseScrubStoma CareSubstance MisuseSurgicalTermination ClinicTheatreUrologyVascular SurgeryWell Man ClinicWell Woman Clinic Please Tick The Areas That Describe Your Work Experience5575304845050 - 6Months6 - 12Months1 - 2Years2 +YearsA & E TrainedA&E ExperiencedAdvance Nurse PractitionerAnaesthetic ExperiencedAnaesthetic TrainedAntenatalBand 6 Nurse CommunityBand 5 General or MentalBand 5 Paeds, PICUBand 6 Nurse SpecialistBand 7 Team ManagerCardiacCardiac Catheter LabCardiothoracicCare of the ElderlyChallenging BehaviourChemotherapyChronic Disease ManagementCommunity NursingCSSDDay Care CentreDay SurgeryDermatologyDistricting NursingEmergency Care PractitionerFamily PlanningGynaecologyHemofiltrationHDU ExperiencedHDU TrainedHealth VisitorsHome CareHospicesHospitalsICU ExperiencedICU NeonatalICU PsychiatricICU TrainedLearning DisabilityMAU/PAUMedicalMental Health000 - 6Months6 - 12Months1 - 2Years2 +YearsA & E TrainedA&E ExperiencedAdvance Nurse PractitionerAnaesthetic ExperiencedAnaesthetic TrainedAntenatalBand 6 Nurse CommunityBand 5 General or MentalBand 5 Paeds, PICUBand 6 Nurse SpecialistBand 7 Team ManagerCardiacCardiac Catheter LabCardiothoracicCare of the ElderlyChallenging BehaviourChemotherapyChronic Disease ManagementCommunity NursingCSSDDay Care CentreDay SurgeryDermatologyDistricting NursingEmergency Care PractitionerFamily PlanningGynaecologyHemofiltrationHDU ExperiencedHDU TrainedHealth VisitorsHome CareHospicesHospitalsICU ExperiencedICU NeonatalICU PsychiatricICU TrainedLearning DisabilityMAU/PAUMedicalMental HealthYears/Months of Experience in the UK: Years/Months of Experience over seas:Employment History(Most recent history first)Full Company Name:Full Address:Line Manager Name:Position:Email Address:Employed as:Employment From(MM/YY):To(MM/YY):Full Company Name:Full Address:Line Manager Name:Position:Email Address:Employed as:Employment From(MM/YY):To(MM/YY):Full Company Name:Full Address:Line Manager Name:Position:Email Address:Employed as:Employment From(MM/YY):To(MM/YY):Reference AuthorisationI hereby authorise Care Zone Recruitment (CZR) to seek references from my current and/or previousemployer(s) or other persons in relation to my personal background, educational attainments, unemployment or job seekers and/or employment history.Print Name:Signed By Agency Worker:Date:Your Bank DetailsName of Bank:BranchName:Account holder Name:Address:Post code:Account Number:Sort Code:I am P.A.Y.E(Please enclose P45 if we are your main employer)□ Yes orI wish to be paid via an Umbrella Company.(Please note, we will provided you with a selection on Umbrella companies that arepart of Bleep360 & Medical 360 approved supply list)□ Yes orI wish to be paid through a Ltd. Company and enclose details.(You will be paid P.A.Y.E until you provide all your documentation to the office)□ YesEMPLOYEE STATEMENT (Read all the following statements carefully and tick the one box that applies to you).A. ? This is my first job since 6 April and I have not been receiving taxable Jobseeker’s Allowance or taxable Incapacity Benefit or a state or occupational pension.B.? This is now my only job, but since last 6 April I have had another job, or have received taxable Jobseeker’s Allowance or Incapacity Benefit. I do not receive a state or occupational pension.C.? I have another job or receive a state or occupational pension.DeclarationsOpt – Out 48 hour Working Week AgreementFor the purpose of the Working Time Regulations 1998, I consent to work in excess of an average of 48 hours per week. I understand that I may withdraw this consent by giving Reliable Healthcare Group Limited not less than one months’ notice. I understand that my registration with Reliable Healthcare Group Limited can be terminated at any time following unsatisfactory work reports.I consent to work. ?I do not consent to work. ?Signed By Agency Worker:Date:Criminal Record and SecurityAs you may be working in an environment where you come into contact with children or vulnerable adults or your assignment may fall within certain expected categories where this is likely to apply, you are legally required to disclose any criminal record under the rehabilitation of offenders act 1974 (exceptions) order 1975. This involves any convictions whether or not they are spent within the act (including any cautions, reprimands, final warnings, bind-overs or any convictions from overseas).Have you ever been convicted of a criminal offence?Yes ? / no ? If yes, please give details below:I confirm that the information given regarding my criminal records is true.Signed By Agency Worker:Date:Bank detailsI have completed my bank details and confirm they are complete and correct. I hereby understand that any incorrect or incomplete details can result in a delay of my payment.Signed By Agency Worker:Date:Compliance UpdatesMany of your compliance items need to be reviewed annually. It is your responsibility to ensure that your file is in date at alltimes. If any of your compliance items lapse, it may cause the suspension and/or termination of your placement.Signed By Agency Worker:Date:Data ProtectionI agree that Care Zone Recruitment (CZR) Limited retains the right to hold this application and any other data required to process it and to pass on to any authorised third party the details held within, also to retain these details for as long as reasonablynecessary in accordance with the Data Protection Act.Signed By Agency Worker:Date:Terms and ConditionsI confirm that the information given in this application is, to the best of my knowledge, true. I am permitted to work in the UK.I understand that my registration is subject to the receipt of at least two satisfactory references and an enhanced disclosure from the Disclosure and Barring Service (DBS).I undertake to inform Care Zone Recruitment (CZR) Limited should I be convicted of an offence in the future.I undertake to inform Care Zone Recruitment (CZR) Limited immediately if I am engaged through their introduction, including the offer of permanent employment following a temporary assignment.I am clear that Care Zone Recruitment (CZR) Limited cannot guarantee assignments and that they have no responsibility to pay for hours not worked no matter the situation.I have read, understood and agree to the conditions of work for temporary nurses, of which I have been given a copy.Signed By Agency Worker:Date:Refer Your Friends Now!We recognise the value of sourcing high-calibre candidates.Our Refer-a-Friend Scheme enables you the chance to receive a generous bonus if you recommend a friend and they successfully complete 5 shifts through Care Zone Recruitment (CZR) Limited *If you know anyone you feel Reliable Healthcare can assist in providing new opportunities or anyone seeking servicing excellence we are keen to speak to them.But before you get started, please remember to let your friend know that we will be contacting them. Please provide us with your friend’s details below:Referral No 1:Job Title:Name:Email:Mobile Number:Referral No 2:Job Title:Name:Email:Mobile Number:Referral No 3:Job Title:Name:Email:Mobile Number:PRIVACY NOTICEThis Privacy Notice tells you what to expect in relation to personal information about you which is collected, handled and processed by ………………………………………………………….. Limited.………………………………………………………………………. of …………………………………………………………………………………….……………………………………………….. (address) is the Data Controller.We acknowledge and agree that any personal data of yours that we handle will be processed in accordance with all current data protection laws in force.?? With effect from 25 May 2018, the General Data Protection Regulations (“GDPR”) will come into force, which will change the law.THE INFORMATION ABOUT YOU WE MAY COLLECT, HOLD AND PROCESS IS SET OUT BELOW:Information collected and processed for finding you a suitable role is as follows:Your nameYour addressYour email addressYour contact numberCV/work historyJob preferences including job role, salary, hourly/rate, geographical areas Any other work related information such as education, training, qualifications Information in respect to individuals that have worked for us previously or may work for us is as follows:Passport/permits/visas Date of birthNational Insurance numberFull details of job offers and placementsOutcome of criminal record checks and security clearance for certain rolesMedical information (if required)ReferencesFinancial information (including but not limited to payroll details and terms, HMRC data, pension scheme details, court orders, statutory payments)A log of our communications with you be email and telephone?This information will have been provided, or will be provided, by you or a third party who we work with, such as a Job Board Company or another employment business or agency.? In the case of references, these will be from your previous employer. Medical information may be supplied by a third party such as your GP, Consultant or Occupational Health.? The outcome of criminal record checks and security clearance checks, where relevant, will be supplied by the Disclosure and Barring Service or other external company applicable to the placement.HOW WE USE THE INFORMATIONThe above information is used to provide our services to you in our capacity as an employment business / employment agency to find you suitable work whether on a temporary or permanent basis based on your requirements as set out on the next page.The information under A may be used as follows:To match your skill sets with job vacancies to assist in finding you the positions that most suit youTo put forward your details to our clients and prospective employers for you to be considered for vacancies they may haveTo place you with our clients and prospective employersTo keep you informed of available opportunities as they ariseTo keep you informed of the services offered by us?The information under B may be used as follows:To verify that you have the right to work in the UKTo enable us to undertake relevant security and criminal record checks as required by our clients and prospective employers and as permitted by lawTo deal with any medical and health and safety issues relating to certain positionsTo put in place contractual arrangements and documentation once a role has been securedTo enable your wages to be processed if you are placed?HOW WE HOLD THE INFORMATIONAll the personal data we have is stored on our secure database in the UK.DISCLOSURE OF YOUR INFORMATIONYour CV and related information will be shared or sent to prospective employers and our clients.? Once you have secured a placement additional information will be provided to them to enable the placement to proceed. Such employers and clients will be located inside the UK.? Personal data shall not be transferred to a country or territory outside the UK.Other trusted third parties that we may share your data with are as follows: HM Revenue and Customs, Government agencies such as the Department for Work & Pensions, pension scheme providers, legal advisors and other companies for the purpose of undertaking pre engagement checks for the role or for paying you.WHAT IS THE LEGAL BASIS FOR PROCESSING THE INFORMATION?We will rely on your consent to process the information set out in A, which is collected at the outset of the recruitment rmation and documentation to establish your right to work is processed by us as we are legally obliged to do so.In respect of medical information, the basis for us processing this will depend on the circumstances, but will usually be for one of the following reasons: it is necessary to protect health and safety or to prevent discrimination on the grounds of disability or where consent has been obtained, if rmation in relation to criminal record checks, which are relevant for some roles, will be processed on the basis that it is necessary for us to comply with the law or consent will be obtained, if required.Once a position has been found for you, we will process your personal data, including financial information, for the purpose of you entering into a contract to fulfil your role and to enable us to pay you, depending on the specific contractual arrangements and circumstances.For the purposes of paying you, where relevant, we are legally obliged to provide information to HMRC.Once a placement has been secured, we may also process your data on the basis of our legitimate interests i.e. for administrative purposes.YOUR RIGHTSYou currently have the right at any time to ask for a copy of the information about you that we hold.? At this time, we have the right to charge a ?10 administration fee for this service.? When the GDPR comes into force, we will no longer have the right to charge a fee.? If you would like to make a request for information please email ………………………………….In addition to this right of access, when the GDPR comes into force, you will also have the following rights: erasure, restriction of processing, objection and data portability.? We will update you further in connection with these rights when they come into force.RETENTION OF YOUR DATAYour data will be retained for no longer than is necessary but in accordance with the legal obligations we are required to meet.WITHDRAWAL OF CONSENTIf you have provided us with your consent to process your data, for the purpose of using our services and us finding you suitable work, you have the right to withdraw this at any time.? In order to do so you should contact us by emailing …………………………………………………………………………CONCERNSIf you have a concern about the way we are collecting or using your personal data, you should raise your concern with us in the first instance or directly to Information Commissioners Office.CONTACTPlease address any queries to [please insert contact details of the person you have nominated as your data controller]CHANGES TO THE PRIVACY NOTICEThis Privacy Notice may be changed by us at any time.? ................
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