APPLY - Intersection Healthcare

“*” indicates required fields

Position applied for

Date of application

1 - Personal Details

Surname

First names

Previous names

Address & postcode

Email address

Home telephone no.

Work telephone no.

Mobile telephone no.

National Insurance number

Current driving license

DO YOU HAVE A CAR FOR WORK USE?

Yes No

Immigration Details

DO YOU NEED A WORK PERMIT?

Yes No

DBS Number

Qualifications / Certified Training

2 - Education

Schools / FE / HE Attended

Examination Grade

Year Obtained

3 - Previous Employment

A full employment history must be detailed beginning with your current employment and covering all reasons for gaps in any given year.

Employer's Name & Date From / To

Position Held, Salary & Benefits

Reason For Leaving

4a - Disciplinary Action

Please detail any disciplinary action within the previous 3 years, including any current, "live" formal warnings

Disciplinary Action

4b - REHABILITATION OF OFFENDERS ACT 1974 - NOTICE TO OFFENDERS

1. Do you have any convictions, cautions, reprimands or final warnings that are not "protected" as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)
2. The amendments to the Exceptions Order 1975 (2013) provide that certain convictions and cautions are protected and are not subject to disclosure to employers and cannot be taken into account.

DO YOU HAVE ANY CONVICTIONS TO DISCLOSE?

Yes No

Any information should be given on a separate sheet and sent with this application form. This information will be treated as confidential and will not necessarily preclude you from employment.
Failure to declare or the falsification of any of the above details will result in the withdrawal of any job offer.

5 - ADDITIONAL PERSONAL DETAILS

Statement of your personal qualities and any experiences which is relevant to the post:

6 - REFERENCES

Please give the name and address of two referees, one of whom must be your current or most recent previous employer. References from relatives or friends are not accepted.

Reference Name

Status

Address & Telephone No

This organisation seeks to work in a flexible and family friendly manner with its staff, however unsocial hours are part and parcel of a quality care service. Weekend working is a requirement for all staff, the frequency of which will be determined at interview.

Please indicate holiday dates if already booked:

Period of notice required in present post:

Earliest Start Date:

Thank you for completing this application form.

I declare that to the best of my knowledge, all the information contained and documented herein is complete and truthful.