STEP 1 PERSONAL INFORMATION

PLEASE FILL-IN COMPLETE INFORMATION

NEXT OF KIN DETAILS IN CASE OF EMERGENCY

BANK DETAILS

STEP 2 QUALIFICATIONS, ELIGIBILITY, EMPLOYMENT HISTORY

PLEASE FILL-IN YOUR QUALIFICATIONS, ELIGIBILITY AND EMPLOYMENT HISTORY

RIGHT TO WORK IN UK

DBS (Disclosure and Barring Service) REQUIREMENTS

Please provide your addresses for the past 5 years

EDUCATION AND TRAINING

Education and training Start with the most recent and work back. Continue on separate sheet if necessary.

MANDATORY AND NON MANDATORY TRAININGS ATTENDED

Please provide certificates.

EMPLOYMENT HISTORY

Please provide details of employment history for the last five years accounting for any breaks in employment (e.g. due to pregnancy, sickness etc.) starting with your current or most recent employer including a contact name. Please account for any intervals of non-employment and include temporary jobs and full-time service.

REFERENCES

Please give details of two UK references. The first reference must be from a professional person within the community (e.g. Nurse, Company Director, Accountant etc.) and the second reference must be from your most recent employer. (Relatives, Family & Friends are not acceptable)

STEP 3 DECLARATIONS, ETHNICITY AND BELIEF

PLEASE READ CAREFULLY AND FILL-IN DECLARATIONS, ETHNICITY AND BELIEF.

IMPORTANT NOTICE: HEALTH DECLARATION

All applicants are reminded that it is unethical for Health Care Workers who know or believe themselves to be infected with any blood borne viruses (HIV, Hepatitis B or C) or other communicable diseases (e.g. Tuberculosis) to
put patients at risk by failing to seek appropriate counseling or by failing to disclose it when notified. Such behavior may affect your ability to practice within the health or social care industry.

I certify that I know of any reason why my health would affect my ability to practice within the health or social care industry.

I understand that no medical details will be disclosed without my permission to any individual other than those necessary and authorized within Legna Care Staffing Ltd

I understand that failure to disclose information or giving of false information may prohibit an offer to temporary staffing assignments.

EQUAL OPPORTUNITIES MONITORING FORM

This form will not be used during the shortlisting process but will be used separately and for the purpose of recruitment monitoring and provision of statistical data. All information supplied will be treated in the strictest confidence.

THE INFORMATION IN THIS FORM IS FOR MONITORING PURPOSES ONLY. IF YOU BELIEVE YOU REQUIRE A ‘REASONABLE ADJUSTMENT’ AT INTERVIEW OR DURING EMPLOYMENT, PLEASE DISCUSS THIS WITH THE RECRUITING MANAGER OR WITH HR.

STARTER DECLARATION

Tick one of the following three statements