Specialist staffing solutions for the healthcare sectors
Our best. Every Day
We have over 25 years experience is the healthcare industry
Providing highly skilled Nurses & Health Care Assistants
Please complete this form in full using BLOCK CAPITALS.
Have you ever been known by any other names?
If Yes, please state ALL names
Place Of Birth
Languages spoken(indicate fluency)
Address including postcode
All contact telephone numbers
Next of Kin/Emergency contact details (phone number/address/relationship):
Do you hold a current valid UK driving licence?
Please state your mode of transport
If you are required to use your car for work purposes, you will be required to have business class insurance. Therefore, we will require a copy of your driving licence and insurance certificate. read and sign:
I confirm I do not have any health issues that could affect my ability to drive
I confirm that my business class 2 is up to date and will be renewed yearly
I confirm that I carry out regular safety checks (tyres, lights, wipers, oil, water etc on my vehicle.
are you currently working?
Reason for leaving
How did you hear of City Force?
Are you eligible to work in the United Kingdom?
Do you require a visa to work in the United Kingdom?
If yes, what type of visa do you hold?
In line with Home Office guidance on the prevention of illegal working we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by City Force Healthcare Ltd for temporary work.
Do you have any spent or unspent* criminal convictions?
Are you currently under investigation and/or do you have any previous convictions including any cautions, reprimands, final warnings, bindovers or any convictions from overseas that are not ‘protected’ under the Rehabilitation or Offenders Act 1974 (Exceptions) Order 1975, as amended in 2013?
*Certain types of employment and professions are exempt from the Rehabilitation of Offenders act 1974 and in those cases, particularly where the employment is sought in relation to positions involving working with children or vulnerable adults, details for all criminal convictions must be given. The information given will be treated in the strictest of confidence and only taken into account where, in the reasonable opinion of City Force Health Care Ltd, the offence is relevant to the position of agency nurse. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment if the offence is not declared but later comes to light. Due to the nature of our business, you are required to submit a DBS check. Do you agree for an enhanced DBS check to be carried out?
Rehabilitation of Offenders Act 1974 (Exception) Order 1975, as amended in 2013 and the Disclosure of Criminal Convictions The position that you are applying for has been identified as exempt under the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975, as amended in 2013 (“the Act”). Applicants are therefore required to disclose information about any convictions, cautions (including reprimands and final warnings provided they are not ‘protected’. Note: The amendments to the Act mean that certain convictions and cautions are now ‘protected’ and do not, therefore, have to be disclosed. Please see separate Guidance for details. If yes, please give details below:1.Date 2.Offence 3.Conviction/Caution 4. Fine/Community Service Order/Prison Sentence
Course title or subject
REFERENCES Please supply the names and contact details for a minimum of two referees. One of these must be from your current or most recent place of employment. References will only be accepted from your direct line manager or HR department. By providing details below you are granting permission for us to apply for your references.
1.Employer 2.Address 3.Position Held 4.Dates to-from 5.Reason for leaving
The Disability Discrimination Act 1995 defines a person as having a disability if he/she has a Physical or Mental impairment which has a substantial and long term adverse effect on his/her ability to carry out normal day-to-day activities. Do you have a disability as defined above Yes/No
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