Complex Care Application Form 1Personal Details2Immigration3Qualifications4Training5Employment History6References7Rehabilitation of Offenders Act8Immunisation Records & Declarations Are you applying for a specific role?(Required) Yes No Role you are applying for(Required)Please select a roleComplex Care Assistant – ChildrensNight Care AssistantComplex Care Assistant RochdaleComplex Care Assistant TamesideComplex Care Assistant BurnleyComplex Care Assistant – Spinal Cord Injury SupportNight Care WorkerCare Co-ordinatorName(Required) Please selectDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Previous Names (if married or changed by deed poll)Date Of Birth(Required) NationalityHome PhoneMobileEmail Address Address Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Full UK Driving Licence? Yes No Driving Licence Number Are you a British or EU National? Yes No Do you hold a valid VISA Yes No Please specify any work RestrictionPassport NumberPassport Expiry Date VISA NumberVISA Expiry Date Please give full details of any academic and vocational qualifications you have undertaken as well as relevant training. Including secondary, further and higher education. Continue on separate sheet of paper if required. Please be prepared to bring original certificates to interview. Qualifications Qualification gained / pending Date achieved Actions Edit Delete There are no Qualifications. Add Qualification Maximum number of qualifications reached. Training Undertaken Moving & Handling Medication administration Basic life support Fire Safety Food & Hygiene Infection control Equality & Diversity Data Protection Safeguarding Adults & Children Health & Safety (incl. COSHH & RIDDOR) Select AllTraining Provider and Certification DateCoursesCourse Training ProviderDate of Certification Add Remove Please give full details of all your previous employment. This should include paid and unpaid employment, work experience and placements. Exact dates of employment must be given. If different posts with the same employer include them separately. Please indicate reasons for any substantial gaps in employment and full-time study on Gap section continue a separate sheet if necessary. Please start with your present employer. If you are not currently in employment, please leave blank. Current EmploymentJob TitleEmployers NameDate Started Employers AddressEmployer Phone NumberName of supervisor / manager / team leaderMay we contact this number? Yes No Reason for leavingPrevious EmploymentPrevious employment Employers name Job role Actions Edit Delete There are no Employments. Add Employment Maximum number of employments reached. Gaps In EmploymentGaps in employment Gap from date Gap to date Actions Edit Delete There are no Gaps. Add Gap Maximum number of gaps reached. Please provide details of two clinical professional referees. One referee must be your current or most recent employer and your previous employer. References are usually taken up before interview/placement. A job will not be offered until references have been obtained. Reference permission I agree to references being taken upReferences are usually taken up before interview/placement. Please indicate your permission if this is acceptable: Professional references Name Company Actions Edit Delete There are no Referees. Add Referee Maximum number of referees reached. Next of kinNameRelationshipPhoneEmail AddressEmergency ContactNameRelationshipPhoneEmail Address By the Rehabilitation of Offenders Act 1974 (Exceptions/Amendments) Order 1986, the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which enables the provider to have access to vulnerable persons in the course of his/her normal duties. Your answer to the following question should therefore include ‘spent ‘duties.Have you ever been convicted of a criminal offence? Yes No I undertake to inform Complex Care Professionals should I be convicted of an offence in the future. Yes No Do you consent to Complex Care Professionals to carry out a DBS check on your behalf Yes No Have there been any proceedings of medical negligence or professional misconduct against you and have you ever been suspended or dismissed Yes No If yes please give detailsHave you ever been included on the POCAL99 Register Yes No The DOH Circular (88, 19), Protection of Children, requires that any professional with access to Children must not be/ have been a named person on the Protection Of Children Act List 99 Register. Immunisation records Agree to provide immunisations recordsI agree to provide evidence of immunisations to Complex Care Professionals Limited If required before starting my first assignment. GP Contact I agree to allow contact to my GPI give Complex Care Professionals permission to contact my GP to obtain further information if necessary The information that you provided will be handled and processed in accordance with the Data Protection Act 1998. It may be used by Complex Care Professionals and will be rely on when screening your application. It uses will also include the prevention and detection of fraud as well as for HR purposes and administration. This information will also form part of your personnel record and will be treated as confidential and will not be disclosed to any unauthorised person. From time to time Complex Care is audited by outside contracted clients and agencies (i.e NHS/CQC) that require your consent. I declare that by signing this form I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Office or any other relevant authority. If I have secured permission to work, I have included copies of all documentation. I also acknowledge that if it is found that I am working without relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities. I declare that the information given in this document is true and complete and is not presented in any way to mislead. I am not aware of any condition, medical or otherwise, which could affect or limit my employment or performance. I agree that if I have or in the future give false, inaccurate, or misleading information made in this application would result invalidate any contract of engagement and in termination without notice. I hereby agree that retains the right to hold this application and any other data required to process it and to pass to any authorised third party the details held within. Also, to retain these details for as long as reasonably necessary in accordance with the Data Protection Act. Form consent I declare that all information given as part of my application is true.
