Application form


Personal Details

Surname: National Insurance number:
Telephone: Account number:
Mobile Sort code:
Address: Bank address:
Postcode: Drivers licence number:
Date of birth: Car registration number:

Employment record (starting most recently)

Name/address of employer: From/to: Job title/responsibilities: Reason for leaving:

Education/Further Education/Membership of Professional Organisations

Dates from/to: School/College Examinations/Qualifications Grade/result

Relevant Training Record & dates courses attended

Course Title: Training Provider/Location: Dates:
e.g. First Aid e.g. NHS - Hull e.g. May 2008

Professional referees

Name: Name:
Position: Position:
Company: Company:
Address: Address:
Telephone: Telephone:
Relationship: Relationship:

Health declaration

All personnel are required to complete this health declaration.
Have you ever had any of the following? (including childhood)
Heart/Circulatory illness Blood disorders
Asthma/hayfever Bronchition, pneumonia, pleurisy
Tuberculosis Epilepsy
Diabetes - recent onset Migraine, headaches
Diabetes - since childhood Anxiety, depression
Dermatitis, psoriasis, eczema Hearing loss
Frequent sore throat Vision defects
Hepatitis/jaundice Colour blind
Bladder/kidney disorder Any deformities (movement)
Indigestion/stomach ulcers Treated for weight loss
Any current infection Diarrhoea/vomiting (6 months)
Any contact with MRSA Any regular prescriptions
Are you registered disabled Recent hospital treatment
Any major operations/illness Any other physical disabilities
Date of last chest X-ray

Have you ever been vaccinated, immunised or tested for the following:

Hepatitis B Heaf, mantoux or tine
Hepatitis B Antibodies Tuberculosis inc BCG
Rubella (German measles) Poliomyelitis
Typhoid MRSA
Tetanus Other
GP's Name/Address:


I declare the information given in this form is true. I am permitted to work in the United Kingdom.
I have read and understood and agree to the conditions of work for temporary workers.
I understand my application is subject to the receipt of satisfactory references & other checks.
I undertake to inform you should I be convicted of any criminal offence in the future.
I undertake to inform you immediately if I am engaged through your introduction, including the offer of permanent employment following a temporary assignment.
I also acknowledge this information I will have access to as determined by the Data Protection Act 1984.
I agree to respect the confidentiality of patients and any other information I have access to at all times.

Professional Indemnity Insurance for carers
Contribution to the scheme is compulsory and is currently £1 per week and automatically deducted from your wage payment.
Under the terms of the scheme you are covered for negligence claims arising out of malpractice to a maximum value.

Role Suitability:

Availability/other interests/commitments/work preferences:

Full or part time hours?
Any hobbies? e.g. darts Weds night, football Saturday etc
Any part time college course?
Children - school hours?

Disability Discrimination Act 1995:

Section one of this act describes a disabled person as a person with a 'physical or mental impairment which has a substantial or long term effect on his/her ability to carry out normal day-to-day activities'.
Using this definition, would you consider yourself disabled? Tick the box for "Yes".
If yes, do you require any special arrangements to be made to assist you if/when called for interview?

Verification of information:

By initialling below, I certify that all inforation I have provided is correct and I understand that any false information I have given may result in a job offer being withdrawn.

Additional information required for criminal record check purposes:

Have you lived anywhere other than your current address in the last 5 years? If yes please list the details below.
Address inc post code: Address inc post code::
Dates: Dates:
Have you ever been known by any other name? If yes please list the details below.
Name: Name:
Dates: Dates:
Place of birth:
Town: Country:
By initialling below, I agree to give my permission for Staff Call UK to use my information within an online application to seek a Criminal Record Check prior to employment.