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1. Personal Details

Post Applied for:

First Name

Date Applied:

Last Name

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Next of kin

Full Name

Relationship

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Additional Information.

Do you drive to work?

Do you have the legal right to work in the UK?

If ‘Yes’ but there are conditions attached, please specify (e.g. start/finish dates/WRS etc. If ‘No’, please note we are unable to recruit anyone who does not have the legal right to work in the UK.

By signing below, you declare that to the best of your belief, the information given above is correct and that you are medically fit and able to work.

Full Name

Upload Signature

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Date / Time

3. Your Work History

Please ensure you complete this section even if you have a Curriculum Vitae. Obshir Health Care requires that ‘Employment history should be recorded on an application form which is signed’. Please ensure that you leave no gaps unaccounted for and it covers 10 years, or up to your education.

Employer Name

Main Responsibilitie

Job Title

Work Address

Date from:

Date to:

Salary

Reasons for Leaving

Employer Name

Main Responsibilitie (copy)

Job Title

Work Address

Date from:

Date to:

Salary

Reasons for Leaving

Employer Name

Main Responsibilitie

Job Title

Work Address

Date from:

Date to:

Salary

Reasons for Leaving

4. Criminal Record Declaration. Criminal Record Declaration

Have you ever been convicted of a criminal offence?

Have you ever received any official cautions, reprimands or warning?

To your knowledge, are you currently the subject of any criminal proceedings or any police investigation? YesNo

If you have answered ‘yes’ to any of these 3 questions, please provide details below

5. References

Please provide the names and contact details of at least 3 referees, the first two must be your present or most recent employer.

Personal referees such as relatives, friends, neighbours etc ARE NOT acceptable as referees.

i) Present employer

First Name (copy) (copy)

Last Name (copy) (copy)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Daytime phone number

Occupation/Relationship of referee:

Contact prior to the interview:

ii) Previous employer

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Daytime phone number

Occupation/Relationship of referee:

Contact prior to the interview:

iii) Reference 3

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Daytime phone number (copy)

Occupation/Relationship of referee:

Contact prior to the interview: (copy)

Email (copy)

6. Applicant Declaration (Please read carefully before signing the application)

1) The information in this form is true and complete. I agree that any deliberate omissions, falsification or misrepresentation on this form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This equally applies to any medical questionnaires I may complete. 2) I confirm that I have not been subject to any cautions or convictions (other than those given above), investigation, disciplinary action, or enquiry into adult/child protection matters or inappropriate behaviour, and that the information I have given in the Criminal Record declaration section is to the best of my knowledge correct.

First Name

Date / Time

Last Name

Upload Signature

Upload your signature here You can upload up to 1 files.

Documents Requested on site visit.

1) Proof of NMC registration (if applicable)
2) Any other additional CERTICATES
3) Copies of Mandatory Training Certificates
4) Copy of your current DBS
5) Copy of your passport and/or work permit
6) Copy of your National Insurance reference card/letter
7) Copy of Certificate of Incorporation if you operate a Limited Company
8) Proof of Limited Company Account Details
9) Proof of record of immunisations
10) 2 Passport sized photographs with your name and signature at the back
11) Proof of address on 3 documents dated within the last 3 months

Name

1. Personal Details

Next of kin

Additional Information.

2. Medical History

3. Your Work History

4. Criminal Record Declaration. Criminal Record Declaration

5. References

i) Present employer

ii) Previous employer

iii) Reference 3

6. Applicant Declaration (Please read carefully before signing the application)

Documents Requested on site visit.

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