Vacancy Title
Vacancy Title
Please tell us how you heard about this vacancy
Last Name
First Name
Address:
Address:
Postcode:
Contact No
E-mail address:
Date of Birth:
Do you hold a full driving licence valid in the UK?
Preferred hours
We like our workers to be willing to work flexibly across the week and need to know when other commitments mean you could not be available to work:
Days / Night
3. Education/Qualifications
High School
Study Dates
Qualification and Grade
Date Obtained
College/University
College/University
Study Dates
Qualification and Grade
Date Obtained
Please upload your CV
Max. size: 128.0 MB
. Employment History
Previous Employment: Please include any previous experience (paid or unpaid), starting with the most recent first. Current or most recent employer
Name of Employer:
Address:
Postcode:
Position Held:
Date Started
Leaving Date:
Reason for Leaving:
Contact Name of Line Manager for reference
Brief description of duties:
Previous employer
Name of Employer:
Address:
Postcode
Position Held:
Date Started:
Leaving Date:
Reason for leaving:
Contact Name of Line Manager for reference:
Brief description of duties:
Previous employer
Name of Employer:
Address:
Postcode
Position Held:
Date Started:
Leaving Date:
Contact Name of Line Manager for reference:
Brief description of duties:
Training and Development
Please use the space below to give details of any training or non-qualification based development which is relevant to the post and supports your application.
Training Course
Course Details (including length of course/nature of training)
Current Membership of any Professional Body/Organisation Please give details:
Convictions/ Disqualifications
To ensure the safety of our clients an Enhanced DBS (formerly CRB) check must be completed for all positions. A criminal record will not necessarily be a bar to obtaining a position with Melburay Limited. If a check is returned and reveals any information, this will be discussed with the applicant. The Director(s) will make a decision as to whether the offer of employment should be withdrawn. Rehabilitation of Offenders Act 1974 (Exceptions)(Amendment) Order 1986 We would draw your attention to the following statement:- “Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act, 1974, by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986. Applicants are, therefore, obliged to disclose information about any convictions which for other purposes would be regarded as ‘spent’ under the provisions of the Act”. Failure to disclose such convictions could result in dismissal or disciplinary action by the employing organisation. Any information given will be confidential and will be considered only in relation to any post to which the conviction applies.
Have you at any time received or had pending, a court conviction in the UK or overseas? If yes please give details.
Are you aware of any Police enquiries undertaken following allegations made against you, in the UK or Overseas? If yes please give details.
Are you subject to any fitness to practice conditions or have you been suspended or dismissed from any job?
If appointed when could you start? Give period of notice if applicable
References
Please give the detail of two references. We will take up professional references once you have been interviewed and provisionally offered a post. Please make sure that you have given the full contact details of your referees so that this does not delay processing reference requests. If you have no employer references, we will take up references with named individuals at colleges where you have studied, or people who know you in a professional capacity. Please do not put down family members or people you live with as referees.
Name of Referee and relationship to you:
Address:
Postcode:
Email:
Tel:
Name of 2nd Referee and relationship to you:
Address:
Postcode
Email:
Tel:
Working Time Regulations
Working Time Regulations
The Working Time Regulations 1998 state that you are unable to work in excess of an average of 48 hours per week (calculated over a 17 week period) unless agreed with the Melburay Limited Personnel that this limit should not apply. Melburay Limited wishes to have an agreement with you, which will apply until terminated by notice: I. The average 48 hour work limit will not apply to you. II. This agreement may be terminated by yourself by giving Melburay Limited 4 weeks written notice. If you accept this proposal please sign below. This section of the application form will then be a record of this agreement between you and Melburay Limited.
Signed:
Date:
Declaration
Statement to be Signed by the Applicant Please complete the following declaration and sign it in the appropriate place below. If this declaration is not completed and signed, your application will not be considered. I agree that Melburay Limited can create and maintain computer and paper records of my personal data and that this will be processed and stored in accordance with the Data Protection Act 1998. I confirm that all the information given by me on this form is correct and accurate and I understand that if any of the information I have provided is later found to be false or misleading, any offer of employment may be withdrawn or employment terminated.
Signed:
Print Name:
Date:
Equal Employment Opportunities Monitoring Questionnaire
Confidential Melburay Limited is an equal opportunities employer and will ensure that no job applicant or employee receives less favourable treatment particularly on the grounds of sex, race, colour, nationality, ethnic origin, marital status, disability, sexuality, age, religious belief, political belief, trade union activity, responsibility for dependants, employment status or HIV status. Please complete this form and return it with the main Application Form to assistant Melburay Limited in monitoring its Recruitment and Selection process. In addition, the information will form part of the employment record for the successful applicant and will be used by Melburay Limited for later equal opportunities monitoring purposes throughout the period of employment. This form is not made available to those conducting the recruitment interview.
Sex
Date of birth
Marital status
* E.g. Individuals who are widowed but have not remarried, individuals who are separated, individuals who are living with a partner etc
Other* (please specify)
Disability It is recognised that disabled people are not only those whose disability is immediately apparent (eg blind people or those in wheelchairs) but also those whose disability is not immediately obvious (eg heart trouble, mental illness or diabetes)
Do you consider yourself as having a disability?
Ethnic origin Individuals should identify with which one of the undernoted categories they most closely associate themselves, having regard to their ethnic or cultural background.
Ethnic origin
White: Other (please specify)
Black: Other (please specify)
Asian: Other (please specify)
Any Other Ethnic Group (please specify)
Post applied for
Print Name:
Signed:
Job Reference:
Date:
HEALTH SELF DECLARATION FORM
HEALTH SELF DECLARATION FORM PLEASE NOTE: If you falsify any information on this form, or fail to mention anything relating to your health which may later come to light, you may be liable for disciplinary action including immediate suspension. You are required to complete the Health Self Declaration Assessment below which must be signed and returned to Melburay Limited Agency prior to the start date.
Do you have any illness/impairment/disability (physical or psychological) which may affect your work, your own health, safety and welfare, or that of others?
If yes, please give details below:
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
If yes, please give details below:
Are you having, or waiting for treatment (including medication) or medical investigation at present?
If your answer is yes, please provide further details of the condition, treatment and dates below.
Do you think you may need any adjustments or assistance to help you to do the job?
If yes, please give details below:
Do you have any of the following?
(a) A cough which has lasted for more than 3 weeks?
(b) Unexplained weight loss?
(c) Unexplained fever?
Have you had tuberculosis (TB) or been in recent contact with open TB?
If yes to any of the above, please give details below:
Health and Safety
As a health care worker, you are under ethical and legal duties to protect the health and safety of the individuals in your care. All information disclosed will be processed in accordance with the requirements of the Data Protection Act Nursing and Allied Professionals Only:
Have you ever had chickenpox/varicella?
Can you provide documented evidence of immunity to measles, mumps and rubella?
Have you had a BCG vaccination in relation to Tuberculosis?
Have you ever had a Hepatitis B test in the last 5 years?
If yes to any of the above, please give details below:
Please provide the following details of your immunisation record:
Tetanus
if yes Dates of immunisation
Diptheria
if yes Dates of immunisation
Poliomyelitis
if yes Dates of immunisation
Hepatitis A
if yes Dates of immunisation
Hepatitis B (showing titre levels > 100miu/ml)
if yes Dates of immunisation
Rubella (German Measles)
if yes Dates of immunisation
Varicella
if yes Dates of immunisation
BCG (Tuberculosis vaccination)
if yes Dates of immunisation
I declare that all of the information provided regarding my declaration of health and immunisation record is true to the best of my knowledge and I will endeavour to inform Melburay Limited of any changes in my health circumstances that may affect my ability to work.
Covid
if yes Dates of immunisation
Signed:
Print Name:
Date:
APPLICATION CHECKLIST In order to ensure that we can register and clear you as quick as possible please use the following checklist to ensure that you have all the documents required: 1. Completed DBS applicationform for England or Scotland 2. The necessary documents to confirm your identity https://www.gov.uk/disclosure-barringservice-check/documents-the-applicant-must-provide3. Melburay Healthcare application form fully completed 4. Details of 2 referees – currentand last employers includinge-mail addresses 5. Evidence of the right to work in theUK 6. Original/Certified Registrationcertificates,professionalqualifications, membershipsof prof bodies 7. NMC Original Statementof Entryor HPC Equivalent 8. NMC Annual Statementof Entryor HPC Equivalent 9. Latest CV 10. Occupational Healthquestionnaire 11. Proof of professional indemnity cover (Qualified Staff) 12. Agency workerhandbook declaration 13. Police check from countryof origin – if you have been in the UK less than 6 moths. 14. OriginalIELTS Certificate- if applicableto you Original Documents: We are required to verify all original documents. We will scan any original documents that you bring. If you bring copies we require a copy of each and every page, i.e. for passports and travel documents, a copy should be taken of the document’s front cover and any page containing the holder’s personal details. In particular, you shouldcopyany pagethat providesdetails of nationality, your photograph,date of birth, signature,date of expiryor biometricdetails.