First Name
Last Name
Phone Number
Email
Address
Postal Code
National Insurance Number (NI Number)
Professional Qualifications
If Yes, What is the name?
Date Joined
Next of Kin
Phone Number
Email
Address
Relationship With Next of Kin
Current Job Title and Brief Description of Duties
Company/Organisation
Date Started
End Date
Disclosure Barring Service: Please note that you will be subjected to an enhanced DBS check. Because you are a healthcare worker, you are not exempted from the rehabilitation of offender ACTS 2010. This means that all convictions, cautions, reprimands and final warnings on your criminal records must be disclosed.
If you answered YES to any of the questions above, please provide full details of the incident below:
1st Referee's Full name
Please ensure that you give a minimum of two references which cover at least the last five years of your employment. The first of your references must be your present employer and your relevant line manager. If you are unemployed, this should be your last employer, or if this is your first job, your head-teacher or college tutor. Please note that Care With Passion Limited reserves the right to take up references in respect of any previous employment paid or unpaid, without further notification to you. You may also provide the name of a personal referee as well as your employment references if you wish. Also ensure that the given contacts are valid. Your references are important.
Name of Organization
Post Code
Phone Number
Email
Job Title
2nd Referee's Full name
Name of Organization
Post Code
Phone Number
Email
Job Title
3rd Referee's Full name
Name of Organisation
Post Code
Phone Number
Email
Job Title
If YES, please give details
Tuberculosis, Rubella (German Measles), Poliomyelitis, Varicella, Tetanus, Hepatitis B.
Name of General Practitioner
Occupational Health Department
Office Address
Because of the nature of the work for which you are applying, the provisions of Section 4(2) of the Rehabilitation of Offenders Act (1974) do not apply by virtue of the Rehabilitation of Offenders Act (1974) (exceptions) Order 1975. Applicants are therefore required to give information about convictions, which for other purposes are '‘pent’ 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.
Date
SUBMIT
