Page 1 of 8

POSITION APPLIED FOR: Health Care Assistant

1: PERSONAL DETAILS (Please use CAPITAL letters)

Title: Mrs/ Miss/ Ms/ Mr/Dr

Mr.

Surname:

Khan

First Name(s)

Mohammad Tayyab

Date of Birth:

20/03/1952

Nationality:

British

Name you prefer to be known by:

Mohammad

Day time phone number:

01274 780934

Mobile number:

07828055445

Email address:

mohammad.tayyabkhan@hotmail.com

Postal address:

88 St Margaret's Ave Bradford BD49BD

Do you hold a full UK drivers licence? YES/NO No

2: PROFFESSIONAL QUALIFICATIONS

Qualification

Degree in Nursing

Year Obtained

1979

Mimosa Staffing, 1506-1508 Coventry Road, Yardley, B25 8AD t: 01213730253 f:

01217647093 e:info@mimosastaffing.co.uk

Page 2 of 8

Professional Body e.g. NMC,GMC etc

Nursing Examination Board Punjab Lahore

Pakistan

Registration Number

3: PASSPORT DETAILS

Nationality: British

Passport number: 515828770

Please tell us about your eligibility to work in the UK

I am eligible to work in the UK and do not require a work
permit
.

Yes

I am already in possession of a work permit to work in the UK

I need to obtain a work permit to work in the UK
If other please specify:

4: EMPLOYEMENT HISTORY

Mimosa Staffing, 1506-1508 Coventry Road, Yardley, B25 8AD t: 01213730253 f:

01217647093 e:info@mimosastaffing.co.uk

Page 3 of 8

Please supply details of your full employment history and explain any gaps in your
history. Continue on a different sheet if required.
Job Title

Employer

Date from

Date to

Care Support
Worker

NHS Professionals

11/11/2011

To Date

Senior Health
Care Assistant

Bupa Knowles
Court N/ Home

01/09/2005

11/11/2011

5: CLINICAL SKILLS (applicable to nurses)

Please place a tick next to options with the clinical area you have expertise in:

Mimosa Staffing, 1506-1508 Coventry Road, Yardley, B25 8AD t: 01213730253 f:

01217647093 e:info@mimosastaffing.co.uk

Page 4 of 8

Have there ever been any proceedings of medical negligence or professional

misconduct, allegations of misconduct against you and have you ever been
A&E

Cardiac

Clinics

Community

Diagnostic Imaging x-ray

Elderly Care

Endoscopy

General Wards

Gynaecology

HDU

Health Visitor

Homecare

ITU

Learning Disabilities

Medical

Mental Health

Midwifery

Neonatal

NICU

Nurse Practitioner

Nursing Homes

Occupational Health

ODP

Oncology

Chemotherapy

Orthopaedics

Paediatric A&E

Paediatrics

Palliative

Paediatric ICU

Practise Nurse

Prison

Radiology

Recovery

Renal

Dialysis

SCBU

Surgical

Theatre

Triage

Urology

Walk in centre

6: PROFESSIONAL CONDUCT
suspended or dismissed? Yes/No
If yes please supply details below:

Mimosa Staffing, 1506-1508 Coventry Road, Yardley, B25 8AD t: 01213730253 f:

01217647093 e:info@mimosastaffing.co.uk

Page 5 of 8

7: REHABILITATION OF OFFENDERS ACT

Because of the nature of the work for which you are applying, Section 4(2), and
further Orders made by the Secretary of State under the provision of this section of
the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 applies.
Applicants are therefore required to give information about convictions which for
other purposes are spent under the provisions of the Act. Any information given will
be completely confidential and will be considered only in relation for positions to
which the order applies. All employment applications will be considered carefully,
and the disclosure of a conviction does not imply that this employment application
will be rejected.
Have you at any time been convicted of an offence?
No If YES, please supply details below:

YES/NO

8: BANK ACCOUNT DETAILS

Name of Bank

One Banking

Branch Name
Account Holder/ Agent Name

Mohammad Tayyab Khan

Sort Code

231884

Account Number

56663804

Bank Address:

Post Code:

All Mimosa Staffing Agency workers are self employed or work through an umbrella
company .Please provide self employment details below if applicable.

Mimosa Staffing, 1506-1508 Coventry Road, Yardley, B25 8AD t: 01213730253 f:

01217647093 e:info@mimosastaffing.co.uk

Page 6 of 8

9: NEXT OF KIN DETAILS

Name

Umer Tayyab Khan

Relationship to you

Son

Day time phone number

Mobile number

07429339642

Address
7 Selbourne Terr
Bradford

Post Code: BD4 9BD

10: REFERENCES- One must be your current or most recent employer

Please supply the names and work addresses of at least 2 clinical professional
referees. One must be of a senior grade than you.
Reference 1 Name
Nahid Khan
Email

nahid.khan@midyorks.nhs.uk

Telephone number

01924 541000

Position

ward Sister

Address

Ward 4 Dewsbury District Hospital

WF13 4HS

In what capacity has this person known you, and for how long have they known you?

Reference 2 Name

Shagufta Shaukat

Mimosa Staffing, 1506-1508 Coventry Road, Yardley, B25 8AD t: 01213730253 f:

01217647093 e:info@mimosastaffing.co.uk

Page 7 of 8

Email

Shagufta.Shaukat@bthft.nhs.uk

Telephone number

01274 542200

Position

Senior Theatre Nurse

Address

Nucleous Theatres Bradford Royal

Infirmary Duckworth Lane Bradford BD9
6RJ

In what capacity has this person known you, and for how long have they known you?

11: DECLARATIONS

a) Terms and Conditions

I certify that the information contained on this application form is accurate and true.
I understand that my registration is subject to the receipt of at least two satisfactory
references and enhanced disclosure from the Criminal Records Bureau.
I undertake to inform Mimosa Staffing should I be convicted of an offence in the
future.
I undertake to inform Mimosa Staffing immediately if I am engaged through their
introduction, including the offer of permanent employment following a temporary
assignment.
I agree to respect the confidentiality of service users and any other information I may
have access to, at all times.
I am clear that Mimosa Staffing cannot guarantee assignments and that they have
no responsibility to pay for hours not worked no matter the situation.
I have read, understood and agree to the conditions of work for temporary workers,
of which I have been given a copy.
Date: 22/05/2015
Signed: MTKhan

Mimosa Staffing, 1506-1508 Coventry Road, Yardley, B25 8AD t: 01213730253 f:

01217647093 e:info@mimosastaffing.co.uk

Page 8 of 8

b) Induction
I am aware that more detailed information on the Staff Handbook and Policy and
procedures can be obtained directly from Mimosa Staffing recruitment office.

Signed: MTKhan

Date: 22/05/2015

c) Working Time Regulations

I am aware of The Working Time Regulations, 1998, and understand their
implications with reference to my Terms & Conditions of Employment. Mimosa
Staffing time-keeping Records will confirm my hours worked on a weekly basis.
Where these records confirm that I have worked in excess of 48 hours per week I
agree that this 48-hour week limit under The Working Time Regulations, 1998, shall
not apply to me.
I understand that I may agree to opt back into the 48-hour week limit at any time,
giving the appropriate two months notice.
Signed: MTKhan

Date: 22/05/2015

d) Bank Details
I have completed my bank details and confirm they are complete and correct. I
hereby understand that any incorrect or incomplete details can result in a delay of
my payment.
Signed: MTKhan

Date: 22/05/2015

e) Data Protection
I agree that Mimosa Staffing retains the right to hold this application and any other
data required to process it and to pass on to any authorised third party the details
held within, also to retain these details for as long as reasonably necessary in
accordance with the Data Protection Act 1988.
Signed: MTKhan

Date: 22/05/2015

Mimosa Staffing, 1506-1508 Coventry Road, Yardley, B25 8AD t: 01213730253 f:

01217647093 e:info@mimosastaffing.co.uk