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Position and Personal Information

Position Applied For(Required)

Approx. no. of hours wanted(Required)

Please enter a number from 1 to 56.

Work Schedule Type(Required)

Part Time Schedules(Required)

Name(Required)

First Last

Previous Surname

Upload file(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB.

Current Address

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Previous Address

Is your current address less than 5 years?(Required)

Yes

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Contact Details

Phone Number(Required)

Email Address(Required)

Transportation

Do you own a transport?(Required)

Yes

Clean current driving license(Required)

How long has your license been held?(Required)

Endorsements(Required)

Education

Which of these have you attended?(Required)

High School

College

University

High School(Required)

Examinations Passed/Qualifications Gained(Required)

Upload file(Required)

Please supply copies of certificates

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB.

College(Required)

Examinations Passed/Qualifications Gained(Required)

Upload file(Required)

Please supply copies of certificates

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB.

University(Required)

Examinations Passed/Qualifications Gained(Required)

Upload file(Required)

Please supply copies of certificates

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB.

Training History/Professional Status

Date of Graduation/Qualification

Location/Details

Notes

Date of Graduation/Qualification

Location/Details

Notes

Date of Graduation/Qualification

Location/Details

Notes

Additional Courses Attended

Subjects

Location

Employment History

Employer/Company Name

Most recent/last employer

Address

Street Address Address Line 2 City ZIP / Postal Code Country

Date Employed

DD slash MM slash YYYY

Nature of Business

Position held and reason for leaving

Salary/Rate

Employer/Company Name

Prior to the employer listed above

Address

Street Address Address Line 2 City ZIP / Postal Code Country

Date Employed

DD slash MM slash YYYY

Nature of Business

Position held and reason for leaving

Salary/Rate

Other Roles

Assistance with Interview and Assessment

Do you require us to make any special arrangements in order for you to participate in the recruitment process? For example, large print forms? Or additional time to complete forms?

Yes

If yes, please give details

This information will not be used in reaching a decision on whether to offer employment.

GP's Name

First Last

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Next of Kin

Name(Required)

First Last

Relationship(Required)

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Medical Conditions (if any)

Identity Details

Nursing and Midwifery Council PIN number

Nurses only

National Insurance Number(Required)

All Applicants

Capacity to work in the UK

Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?(Required)

Yes

If yes, please provide details.(Required)

If you are successful in the application, would you require a work permit prior to taking up employment?(Required)

Note: Minimum age legislation dictates that Care workers in general must be 16 years old or older. Please inform your interviewer immediately if you do not meet these specifications.

Yes

Referees

You must provide references from your two most recent employers. Please provide an additional character referee. All will be contacted, therefore please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.

Employer Name(Required)

Current or most recent employer

Job Title(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Phone Number(Required)

Email Address(Required)

Previous Employer

Previous employer to the one above

Employer Name(Required)

Previous employer to the one above

Job Title(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Phone Number(Required)

Email Address(Required)

Character Reference

Name(Required)

Full Name

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Phone Number(Required)

Email Address(Required)

Relationship to you(Required)

Criminal Record

Workers of The Agency are subject to the Health and Social Care Act 2008, and will be subject to a Police Record check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions. Please note, you may not be eligible for work in a Care setting if you are on the DBS Register(s).

Do you have a DBS number?(Required)

Yes

Enter your DBS number(Required)

Criminal Convictions(Required)

Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.

Signature and Declaration - Please read before signing

I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately. I understand that I may not be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise Pegail Ltd to request a DBS Register check and a criminal record check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred Care workers, or withdrawal of any registration required by my employment status.

Signature(Required)

Start signing your signature here

Hidden

Date Signed

Gaps in Employment

It is essential to check the continuity of employment, as stated in the application form, and to note and investigate any gaps in employment. Failure to carry through such checks has been identified as a significant factor in several recent abuse cases. Use the “timeline” below to place in order all stated instances of employment and other activities (such as training), and identify any gaps for discussion during the interview. Assess and record the results of the enquiries, which must be followed through if interview answers are unsatisfactory. The period considered must be the whole working life of the applicant, to date.

From When?

DD slash MM slash YYYY

To When?

DD slash MM slash YYYY

Reason for break

From When?

DD slash MM slash YYYY

To When?

DD slash MM slash YYYY

Reason for break

To When?

DD slash MM slash YYYY

From When?

DD slash MM slash YYYY

Reason for break

GDPR Approval(Required)

I agree to the terms and privacy policy of Resilience HCP

This field is for validation purposes and should be left unchanged.

Join Resilience HCP

Position and Personal Information

Current Address

Previous Address

Contact Details

Transportation

Education

Training History/Professional Status

Additional Courses Attended

Employment History

Assistance with Interview and Assessment

Next of Kin

Identity Details

Capacity to work in the UK

Referees

Previous Employer

Character Reference

Criminal Record

Signature and Declaration - Please read before signing

Gaps in Employment