i

Child Protection Investigation Y

Yes / No
I
p
a
Please be advised that the post for which you are applying may require the official Disclosure of all
c
S


o
D








S D






Employment Application Form
Post applied for .................................... Location ..................
Personal details
Surname: .............................. Title .. First name(s) ........................
Maiden name ........................ Previous married name .............................
Address .....................
..................
Postcode: ......... E-mail: ...............
Tel no. (Home) ............. (Mobile) ..... (Work) ...............
Date of birth ......................... Marital status .................
Are you a car owner? Yes / No
Do you hold a clean and full driving Licence? Yes / No
Do you have the right to work in the UK? Yes / No
Do you require a work permit for employment in the UK? Yes / No
Education, further education and qualifications
Please list details of school and any degrees, professional qualifications or membership of professional organisations and
Institutes. (Continue on a separate sheet if necessary)
Establishment Qualifications Dates
..................
..................
..................
......................
..................
..................
Membership of professional body
Registered Nurses should quote their NMC Personal Identification Number and expiry date
Awarding body Registration number Expiry date
... .. .............
Nurses, you will be required to show your NMC PIN at interview together with two forms of identification (one being
photographic, e.g. a passport or new style driving licence). Please also bring with you a copy of vaccination confirmation.







s



convictions or cautions
w T

I





would lead to either your application being refused, or
i
All information given on this form will be
k



Yes /


Yes / No
o (This includes any driving/motoring offences).
H dismissal or disciplinary proceedings? Yes / No
H Yes / No
h
Details of courses attended
Please list any training courses that you have attended, including mandatory training courses.
(Continue on separate sheet if necessary).
Subject Duration Date
..................
..................
..................
..................
.................
Career history
Please list your previous employers commencing with the most recent (continue on a separate sheet if necessary).
Detail any reason for gaps in your employment.
Dates Company Position held Reason for leaving Salary
..................
..................
..................
..................
..................
..................
..................
..................
..................
Referees
Two employment referees are required in all circumstances, ideally these should be your current and previous employer.
These referees may contacted before interview. Please indicate if this is not acceptable.
Company Name ........... Company Name ..........
Contact Name .............. Contact Name ............
Referee's Job Title ............... Referee's Job Title ...........
Company address .............. Company address .............
......... .......................
......... .........
........ ......
Telephone Number ......... Telephone Number ......
Email ........................... Email ........................
Who has known me...... years Who has known me ..... years
Relationship to me .......... Relationship to me ..
Have you
Hobbies and interests
Please give details of any special interests or hobbies.
...................
...................
...................
How did you become aware of this vacancy?
...................
When would you be available if offered employment?
...................
Additional information
Please state your reasons for applying for this post and give any other professional / personal information you believe would
support your application. (continue on a separate sheet if necessary)
...................
...................
...................
...................
...................
...................
...................
Declaration subject to the Rehabilitation of Offenders act 1974 (exceptions) order 1975
and fitness to practice
Because of the nature of the work for which you are applying, this post is exempt from the Rehabilitation of
Offenders Act 1974 and you are therefore not entitled to withhold information about convictions or cautions
which for other purposes are considered spent under the provisions of the Act. This information will be treated
in confidence and will not debar you from employment unless the selection panel considers that it renders you
unsuitable for appointment. In reaching such a decision the company will consider the nature of the
conviction/action, how long ago it took place and any other relevant factors.
Additionally, all staff employed by Transform are required to give a declaration stating whether or not you have
been, or are the subject of any fitness to practice proceedings by any UK or overseas licensing or regulatory
body. You are also required to make a declaration stating whether you have been, or are currently, the subject
of any police investigation or conviction in this or any other country.
Failure to disclose any conviction, caution or investigation would lead to either your application being refused, or
if in the event of subsequent employment any failure to disclose could result in disciplinary action, including
dismissal with details being passed to the individuals Registered Body. All information given on this form will be
kept
(This includes any driving/motoring offences).
in strict confidence.
Please answer the following questions by circling the appropriate response:
ever been, or are currently the subject of any police investigation in this or any other country? Yes / No
Have you
Have you
ever been convicted of any criminal offence, or bound over, or cautioned in respect of any such Yes / No
offence, in this or any another country? (This includes any driving/motoring offences).
Have you ever been subject to any form of complaint: dismissal or disciplinary proceedings? Yes / No
Have you ever been, or are currently, the subject to fitness to practice proceedings by any body Yes / No
having regulatory functions in this or any other country?
D




D
D Company Position held Reason for leaving Salary

Please indicate if this is not acceptable.
C Company Name ..........
C Contact Name ............
R

.......................
. .........
......
T
Who has known me ..... years
R Relationship to me ..
Have you ever personally been the subject of, or employed or in any way associated with, an establishment/agency
which has been the subject of a
1. Police Investigation Yes / No
2. Inspection Unit of Care Quality Commission Yes / No
3. Child Protection Investigation Yes / No
4. Adult Protection Investigation Yes / No
5. Proceedings under the Registered Homes Act 1984, Residential Care Home Regulations 1989,
Care Standards Act 2000 Yes / No
6. Proceedings under the Children Act 1989, Childrens Homes Regulation 2001, or Fostering or
Adoption Regulations 2002 Yes / No
7. Proceedings under the Nursing Homes and Mental Nursing Home Regulations 1984 Yes / No
If you answer YES to any of the above questions, please provide details on the reverse of this sheet of the nature of the
proceedings undertaken, or contemplated, including the date of proceedings, country where proceedings where undertaken
and the name and address of the licensing or regulatory body concerned.
IMPORTANT: Please be advised that the post for which you are applying may require the official Disclosure of all
criminal record information and other relevant non-conviction information through DBS (Disclosure & Barring
Service) Certificate at enhanced level.
Data Protection Act
I understand that, if offered employment with the company, the information I have given will be collected and securely retained
on computer and manual form for employment administration and payroll purposes only.
Declaration
I declare that to the best of my knowledge and belief the information given is true, and I understand that
employment will be considered subject to the particulars being correct. I further understand and accept that if
any of the information given in this document is incorrect or untrue, that the company reserves the right to instigate
disciplinary proceedings which may lead to the termination of my employment.
I also declare that having completed the section preceding regarding exemption from the Rehabilitation of
Offenders Act, I confirm that if, during employment with Transform, I subsequently am in receipt of investigation,
caution, or conviction from the Police, Health or any other regulatory or licensing body, I have a duty to inform
the company of this fact.
Signature ......... Date ..........
Please
HR Department
Transform Medical Group
192 Altrincham Road
Manchester
M22 4RZ
return your completed form to:

L

First n
Previous married name .............................
A
...............
T ............. (Mobile) ..... (W
......................... Marital status .................
A Y / No
D / No
D / No
D / No
E

I (Continue on a separate sheet if necessary)
E



.. .............
N

HR003/09/13