Online Application – Care Connex

Application Form

Step 1 of 8

Your Photo

Upload/Capture Your Photo Here:

Accepted file types: jpg, jpeg, png, gif.

Date Photo Taken

If you "Captured" the photo please enter today's date. If you "Uploaded" the photo, kindly specify when that photo was taken.

Personal Details

Name(Required)

Title Fornames Surname

Date Of Birth(Required)

The Role You Are Applying For :

Phone Number(Required)

Email(Required)

Nationality(Required)

National Insurance Number

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?(Required)

Yes

Rather not say

QUALIFICATIONS

ACADEMIC QUALIFICATIONS(Required)

(All qualifications will be subject to a satisfactory check).

Institute/Location of Study:

Date From:

Date To:

Examinations, Qualifications*

PROFESSIONAL QUALIFICATIONS

Name of Organisation/ Institute

Date From:

Date To:

Qualification Details

Attach Supporting Documents

Drop files here or

Max. file size: 256 MB.

Upload CV, Passport, Biometric IDs, Training Certificates, etc.

EMPLOYMENT HISTORY

Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained.

CURRENT EMPLOYMENT INFORMATION

Employer Name

Position Held

Duties:

Start Date:

End Date:

Reason for Leaving

Contact Name (Employer)

Employer Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Postcode

Telephone

10 YEARS EMPLOYMENT HISTORY – PLEASE INCLUDE AND DETAIL ANY GAPS

10 YEARS EMPLOYMENT HISTORY

Employer Name:

Position Held:

Start Date:

End Date:

Reason for Leaving:

COMMUNITY, VOLUNTARY OR INTERN EXPERIENCE

Employer Name:

Position Held:

Start Date:

End Date:

Reason for Leaving:

Explanation of Gaps

(Use this section to detail any gaps in employment and why)

Detailed Employment Gaps

PERMISSION TO WORK IN THE UK

Are there any restrictions on your Right to Work in the UK that may prevent your employment opportunity with Care Connex?(Required)

Yes

If your application is successful, would you be required to provide evidence that you have the right to work in the UK?(Required)

Yes

NMC PIN & INDEMNITY INSURANCE (Registered Nurses Only)

Are you a Registered Nurse?(Required)

Yes

SKILLS AND EXPERIENCE

In support of your application, please detail any relevant experiences and personal qualities which you believe are relevant to the position you’re applying for:

Relevant Supporting Experiences/Qualities

PROFESSIONAL REFERENCES

Please provide full names and address of two professional employment referees and one character referee. Your first reference must be from your current or previous last place of work and must be from your line manager. Employment references cannot be sent to private or personal home addresses. You must provide workplace addresses and the referee must be a higher grade of staff than yourself i.e. your line manager

PROFESSIONAL REFERENCES

Name

Job Title

Relationship

Company

Address

Phone Number

CHARACTER REFERENCES

Name

Job Title

Relationship

Company

Address

Phone Number

EMERGENCY CONTACT DETAILS ( should be based in the UK )

Name

Job Title

Relationship

Company

Address

Phone Number

Disclosure & Barring Services Check

Do you have any criminal conviction/cautions in the UK or abroad? (whether related to work or not):

Yes

Are you/have you been under/ or undergoing any clinical investigation, disciplinary or suspension process pending or otherwise?

Yes

The post you are applying for is subject to the Rehabilitation of Offenders Act 1974 and a Disclosure is to be made to the Criminal Records Bureau you must declare all criminal convictions, including those that would otherwise be considered spent. Please note that failure to disclose information regarding any cautions and convictions could result in a withdrawal of a job offer, or in the event of employment, dismissal or disciplinary action. Should I be offered employment, I accept that I will be required to notify the company of any changes to my DBS status.

Confidentiality

If you are successful in your application for employment with Care Connex, you are required to preserve the confidentiality of any information regarding patients, staff and the practice business and this obligation shall continue indefinitely. A breach of this requirement will be regarded as gross misconduct and as such will be grounds for dismissal, subject to the provision of the disciplinary procedure.

Data Processing

Personal information collected on this declaration will be processed and stored in full accordance with the Data Protection Act 1998 and the General Data Protection Regulation 2018. In line with the legislation Care Connex files are kept securely in a safe and secure location. You understand that any personal detail held by Care Connex may be accessed from time to time by inspectors from the care quality commission, other regulatory bodies and designated individuals in line with contractual obligations.

Working Time Regulations 1998

The European Union has laid down guidelines for all workers, governing the length of the maximum working week that is safe to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered, you will not be compelled to work more than 48 hours per week, however you may choose to do so.

Please tick the appropriate box to confirm that you have read and understood the above information.(Required)

I DO NOT wish to work more than 48 hrs per week*

I DO wish to work more than 48 hrs per week

Employment with Care Connex

It is Care Connex policy to employ the most suitably qualified personnel and to ensure equal opportunity for the advancement of employee. This includes promotion and training and to prohibit discrimination against any individual on the basis of race, colour, ethnicity, nationality, sexual orientation, gender, religion, belief, pregnancy, marital or civil partnership status, age or disability. In completion of this application form, I authorise Care Connex to obtain references to support this application once an offer has been made and accepted. I release Care Connex and submitted referees from any liability caused by giving and receiving any information. I confirm that the information given on this form is to the best of my knowledge, true and complete and that the provision of any false statement(s) will be sufficient cause for rejection or if employed, dismissal.

Authorisation Agreement

I authorise Care Connex to contact my referees to obtain my past employment and professional activities. I also agree to release from liability all persons and companies providing this information. I understand and acknowledge that any offer of employment is conditional upon Care Connex being completely satisfied with the information provided as a result of a reference check

By signing this application form you have confirmed that you have read, understood and accepted all of the above.

Signature (Optional)

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Application Form

Your Photo

Personal Details

QUALIFICATIONS

EMPLOYMENT HISTORY

CURRENT EMPLOYMENT INFORMATION

10 YEARS EMPLOYMENT HISTORY – PLEASE INCLUDE AND DETAIL ANY GAPS

COMMUNITY, VOLUNTARY OR INTERN EXPERIENCE

Explanation of Gaps

PERMISSION TO WORK IN THE UK

NMC PIN & INDEMNITY INSURANCE (Registered Nurses Only)

SKILLS AND EXPERIENCE

PROFESSIONAL REFERENCES

Disclosure & Barring Services Check

Confidentiality

Data Processing

Working Time Regulations 1998

Employment with Care Connex

Authorisation Agreement