EMPLOYMENT APPLICATION FORM
most recent first and continue on a separate page, if necessary
May we approach this referee prior to interview ?
Reference 2
May we approach this referee prior to interview ?
From:
To:
From:
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From:
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Have you ever been convicted of any criminal offence?
Do you have any criminal charges pending?
N.B. Any information disclosed will be taken into consideration but will not
automatically prevent the progress of your application.
I have declared all criminal convictions,
whether spent or not, charges, warning and cautions.
The information that you provide on this form and that obtained from other relevant
sources will be used to process your application for employment. The personal information
that you give us will also be used in a confidential manner to help us monitor our
recruitment process. We may disclose your information to carefully selected third parties
who may process data on our behalf or any of our clients for the purpose of ascertaining
your suitability for a particular assignment. If you are appointed, the information will be
used in the administration of your employment with us. We may also use the information if
there is a complaint or legal challenge relevant to this recruitment process. We may check
the information collected with third parties or with other information held by us. We may
also use or pass them to certain third parties in order to prevent or detect crime or in
other ways as permitted by law.
By signing this application form, we will be assuming
that you agree to the processing of sensitive personal data, as [described above], in
accordance with our registration with the Data Protection Commissioner.
I declare that
the information set out in this form is true and correct. I understand and agree that if I
submit any false or misleading information, this may result in any offer of employment with
the Company being withdrawn, or, if already accepted will lead to dismissal.
I hereby
authorise MillyCare Agency to collect all information it may require in connection with my
application for employment.
I confirm that I have read and understood the Conditions of
Engagement offered by the Company and agreed to comply with them and to be bound by
them.
I have no objection to my details being held on computer records and utilised by
the company in pursuit of its legitimate business. I understand that my application is
subject to the receipt of satisfactory references, DBS (Disclosure & Barring Service)
checks, and my ISA (Independent Safeguarding Authority) Register status.
I you agree to inform MillyCare Agency of any changes to the
information you have supplied?.
Please answer the following questions by ticking the appropriate YES/NO box. If the
answer to any question is YES, then please give details in the space
provided below. It is your responsibility to inform us
immediately if any of the following information changes. Have you ever had in your life,
including childhood, any of the following?
Heart/Ciruculation illness/Hypertension
Blood Disorders e.g. Anaemia, Haemophilia
Eye Disease/Injury or Defect
Asthma, Hay Fever
Bronchitis, Pneumonia, Pleurisy
Tuberculosis
Diabetes
Epilepsy, Frequent Fainting Attacks
Headaches, Migraine
Psychiatric Treatment
Dermatitis, Psoriasis, Eczema, Skin Sensitivities
Chicken Pox
Hearing Loss, Frequent Ear Infections
Hepatitis / Jaundice
Bladder Kidney Infection
Gynaecological Problems, Painful Periods
Gastric Ailments, Ulcer
Back Pain, Sciatica or Deformities of the spine
Varicose Veins
Do you have any deformities which affect movements?
Are you receiving any medication from a Doctor?
Have you ever been treated at hospital?
Are you registered Disabled Person
I declare that all the following statements are true and
complete to the best of my knowledge and belief. I hereby give MillyCare Agency the
permission to contact my General Practitioner to obtain further information should
it be required
Please provide the Name and Address of your GP
(General Practitioners)
MillyCare Agency aims to be an equal opportunity employer and recruitment agency and seeks
to ensure that job applicants are interviewed and/or put forward for vacancies solely on the
basis of merit, irrespective of race, disability, age, gender, in order to monitor the
effectiveness of our policy. We request all job applicants to provide the information
requested below.
Thank you for you co-operation. The information given is for statistical monitoring purposes
only.
Please make sure that you read all the categories listed below and then, tick/ circle the
appropriate buttons:
Note: According to the Disability Discrimination Act 1995. ‘Disability’ includes any
physical or mental impairment which may have a substantial and/ or long term adverse
effect on your ability to carry out some or all normal activities of the job for which
you are applying.
Please make sure you read all the categories listed below and then tick the appropriate
code numbers that best describe your ethnic origin. Ethnic origin could be the origin of
your role bearers, so it is not necessarily the same as nationality.
I am Asian
I am Black
(Passport, Official document, eligibility to work in the UK)
(Full Driving License, Utillity bills, Bank Statements and must be within the last 3 month)
(Rubella, Hepatitis B, Varicella, Tuberculosis)
(NI Card, NI Letter or any other Official document containing your NI Number)
(Qualified Nurses Only)
(Formerly known as CRB Disclosure)
Ensure Every aspect of this form is properly completed. Kindly go over again before clicking the submit button!