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Personal Details - Step 1 of 6

Job title you are applying for *

NMC PIN

Only if you are a registered nurse

Title

Name *

First

Middle

Last

Date of Birth *

Country of birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Nationality *

Email *

Phone number *

National Insurance Number *

Do you hold a full & valid driving license for the UK? *

Are you eligible to work in the UK? *

Do you require a work permit? *

If Yes, please detail what type of work permit do you hold and how many hours a week are you allowed to work per week. *

How have you heard about us? *

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Employment History *

Briefly detail your employment history within the past 5 years, starting with the most recent. Please include the dates, FROM/TO. Detail any employment gaps within this period.

Training and Education *

Was your mandatory training - for example moving & handling, infection control, safeguarding, medication admin (RNs only) completed within the last year? Briefly outline any qualifications as well as professional & vocational training that you feel are relevant to this job

Mandatory Training

Moving and Handling
Basic Life Support
Fire Safety
COSH
GDPR
Infection Control
Food Hygiene
Health and Safety

Please tick if you have completed the above training within the last 12 months. Please enclose copies of your training certificates.

Upload Certificates

Click or drag files to this area to upload. You can upload up to 12 files.

DBS status. Have you subscribed for the DBS Update Service? Please select. *

If you selected "Yes", please enter the number of the DBS certificate you subscribe with? Please note this is the DBS certificate number, not your subscription number.

Previous Convictions *

Please give details of any convictions in this country or abroad you currently or have previously had. If none, please write the word “NONE” in this box. Please be aware that it is an offence to withhold this information.

References *

Please give details of two people that would be prepared to give you a reference. One must be from a current/previous employer; the other should be a character reference, from someone other than a family member. Any offer of employment will be subject to satisfactory references. By entering their details here, you give ESN-TIAL Ltd. permission to contact these people. Please include Name, Position, Organisation, Address, Email and Phone Number

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Emergency contact - Full Name *

Emergency contact - Phone number *

Health and Safety - Do you have a disability of any kind that may affect your work? please select. *

If you selected "Yes", please give details …

Have you worked night shifts before? *

If you have worked night shifts before, have they casued any medical problems to you? *

Please describe what type of medical issues have you experienced after working night shifts. *

Do you sleep during the day after a night shift? *

Working Preferences *

Day Shifts
Night Shifts
Weekdays
Weekends

How many days/nights per week? *

One
Two
Three
Four
Flexible

UTR/Company name *

How would you like to be paid? *

Name of Bank/Building Society: *

Account Name: *

Account No: *

Sort Code: *

Online data - We keep many of your records securely online. In addition, clients may ask that these are uploaded and shared online with their own client base (e.g. nursing & care homes), prior to the commencement of your first shift with them. Do you authorize that these details can be shared with them online? *

Working time regulations - the maximum working week is currently limited to 48 hours. As you are under no obligation to accept any work offered, you will not be compelled to work more than 48 hours per week. However, you may choose to do so. Please select. *

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Data Protection *

Our records, including any copies of documents supplied are kept securely in line with GDPR regulations. You understand & give permission for these to be made available from time to time to authorized personnel or inspectors, Home Office Immigration Check. If applicable, you understand & give permission for ESN-TIAL Ltd. to contact the appropriate authority in order to verify your current immigration status. Please tick.

Upload 1 (one) Category A supportive documents: • Current and valid UK Passport. • UK driving license photo card • UK Original Birth Certificate • A UK biometric residence permit card. *

Click or drag a file to this area to upload.

Upload 2 (two) Category B supportive documents: • A Bank or Building Society statement - less than 3 month old. • Utility Bill less than 3 month old. • A Credit Card statement • A Council Tax statement. • A mortgage statement. • A letter from: HMRC, Dept. of Works and Pensions, Jobcentre Plus or any other employment service. • A P45 or P60 statement, A pension or endowment or ISA statement. *

Click or drag files to this area to upload. You can upload up to 2 files.

Upload a Passport Style photograph. It must be clear, full face, no hats and against a white background. *

Click or drag a file to this area to upload.

Lastly, please upload your CV

Click or drag a file to this area to upload.

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Hep B *

TB *

Varicella *

Measles *

Rubella *

Hep C *

No Proof
Negative
Positive

Hep B Antigen *

No Proof
Negative
Positive

HIV *

No Proof
Negative
Positive

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HEALTH AND SAFETY *

Each agency worker has a responsibility at the start of their first shift to become familiar with the Client’s general policies including, without limitation, those relating to Emergency Call Procedures, the Hot Spot Mechanism for alerting security staff that an individual is in trouble, Fire Policy and the Violent Episode Policy.

Declaration *

I confirm that I have read and understood the above and confirm my answers to be accurate and correct. Additionally, I understand that: It is my responsibility to update ESN-TIAL Ltd. in the event any of these details change in the future. Any job offer made to me is based on a zero-hours contract with no guarantee of work or working hours. Any job offer made to me is subject to satisfactory references being obtained from the individuals offered above. I give permission for ESN-TIAL Ltd. to contact the referees given. Upon acceptance, if I do not subscribe to the DBS Update Service, ESN-TIAL Ltd. will arrange a Disclosure and Barring Service (DBS) check now, and at intervals thereafter. I agree to pay the cost of this, determined at the time, either through deductions from my wages, or paid directly by me after three months from the DBS request being made, whichever is sooner. I also understand that ESN-TIAL Ltd. may contact the Home Office/UK immigration in order to verify my eligibility to work in the UK. If information given on this application form is found to be false it may result in disciplinary action, or dismissal.

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