Title Forename(s) Surname
Address Line 1 Address Line 2 Address Line 3 Address Line 4 Postcode
Home Tel Mobile Tel
Email Address
Preferred Method of Contact Phone E-Mail Text
Gender --- Male Female
Date Of Birth Nationality Country of Birth
Do you hold a driving licence? --- Yes No Licence Type Penalty Points
Do you own a vehicle? --- Yes No If yes, what vehicle
National Insurance Number
Do you hold a current DBS on the update service? --- Yes No If yes, enter the DBS number
Have you been known by any other names? Please include maiden name, if applicable.
Forename(s) Surname) From To
Forename(s) Surname From To
Work Requirements
Are you an EU Citizen? --- Yes No Do you hold a British or EU Passport? --- Yes No If no, do you have a valid Work Permit/Visa? --- Yes No Please tell us the expiry date of this visa
Section 2 - Additional Information
Uniform Size
Next of Kin
Name Relationship Tel Mother's Maiden Name
Section 3 - Education
Please indicate the amount of the following qualifications you hold:
NVQ/Diploma (please state subject and grade achieved)
A-Levels/A.S Levels/Degree (please state subject(s) and grade achieved)
Please state the name of the school(s)/college(s)/university(s) you attended when gaining the qualification(s) detailed
If applicable, please state the year that you passed your Nursing Qualification and the Establishment where you studied at:
Year Establishment
Section 4 - Professional Registrations
Please supply registration details for the following roles: Doctors, Nurses/Midwives, Allied Health
Professional Body Registration Number Expiry Date Date of Application Application Number
Professional Body Registration Number Expiry Date Date of Application Application Number
Section 5 - Address History
Please provide your previous five year address history (ensuring post codes are given):
Current Address Post Code From (month and year) To (month and year)
1st Previous Address Post Code From (month and year) To (month and year)
2nd Previous Address Post Code From (month and year) To (month and year)
Section 6 - Employment History and References
Please provide your full work history from leaving school to the present day. Please also account for any gaps in your employment history.
Please give the names and contact details of two professional referees from your current and previous employment/assignment, to cover at least 3 years of employment/training or assignment. Referees must have worked in a senior position to yourself. Agency Workers applying to operate in the NHS must provide referees whom can comment on your clinical abilities which is relevant to the role you will be assigned to. At least one clinical reference must be dated within the last 12 months of application.
Current Employer Name Address Post Code Job Title Start Date Finish Date Reason for Leaving Referee Name Referees Professional Title Capacity in which known Telephone Fax E-Mail Address
Previous Employer Name Address Post Code Job Title Start Date Finish Date Reason for leaving Referee Name Referees Professional Title Capacity in which known Telephone Fax E-Mail Address
Section 7 - Training Courses
Please supply details of any relevant training. Please provide documentary evidence of the below, all certificates must be verified.
Qualification/Training Course Place where obtained From (Month/Year) To (Month/Year)
Qualification/Training Course Place where obtained From (Month/Year) To (Month/Year)
Section 8 - Professional Indemnity Insurance
Precedo Healthcare recommends that you have your own Professional Indemnity Insurance in place if you wish to operate as a Limited Company
Do you already have this? --- Yes No N/A
If yes, please detail whom this is with and level of cover
Thank you for registering with The Company. Once we have received your completed registration pack and you have successfully attended interview, The Company will begin to gather your documents and take you through the registration process from start to finish. This process usually takes a maximum of four weeks. Please note, agency workers will be requested to apply for an enhanced Disclosure produced online by the Disclosure and Barring Service at a cost of £50.00, unless an Update Service Code is available. This payment once received is completely non-refundable.
Section 9 - Additional Information
Please include any additional information you believe may be important to support your registration, including any additional clinical skills and experience you feel is relevant
Section 10 - Declarations
Criminal Records
The agency work you have registered for is exempt from the Rehabilitation of Offenders Act 1974 therefore any spent or unspent convictions, cautions, reprimands and final warnings on your criminal record must be disclosed. Guidance and criteria on the filtering of these cautions and convictions can be found at the Disclosure and Barring service website. A spent or unspent conviction will not necessarily prohibit agency workers from full registration with The Company, only relevant convictions and other information will be taken into account. Please answer the following:
1. Have you ever been convicted by the courts or cautioned, reprimanded or given a warning by the Police? (Including countries outside the UK)
--- Yes No
2. Are you currently the subject of any police enquiries or investigation, following allegations made against you? (Including countries outside the UK)
--- Yes No
If you have answered yes to any of the above please give details below:
3. Have you ever been subject to disciplinary action or are you currently under investigation or suspension by a current or previous employer/contractor due to alleged misconduct or poor performance, in the UK or overseas?
--- Yes No
4. Have you ever been disqualified from practice of a profession, or require to practice subject to specified limitations following fitness to practice proceedings by a regulatory body e.g. NMC/HPC. in the UK or overseas?
--- Yes No
If you have answered yes to any of the above please give details below:
I hereby give my consent to the Company to process the following information:
Personal data, including name, date of birth, contact details, including telephone number, email address and postal address, experience, training and qualifications, CV, National Insurance Number, sensitive personal data including disability/health assessments relevant to the role, criminal convictions/DBS checks and reference checks.
I consent to the company processing the above personal data for the following purposes:
For the Company to provide me with work-finding services
For the Company to process with or transfer my personal data to their named client/s in order to provide me with work-finding services.
For the Company to process my data on a computerised database provided by named provider in order to provide me with work-finding services
For the Company to process my data using automated decision making processes
I acknowledge and confirm that The Company is authorised to apply for and obtain references from any previous employers and educational establishments and agree that these organisations may release my information
I also consent to the Company processing my personal data with third parties for the purposes of internal audits and investigations carried out on the Company to ensure that the Company is complying with all relevant laws and obligations.
The consent I give to the Company will last for one year from providing me with work finding services.
I am aware that I have the right to withdraw my consent at any time by informing the Company that I wish to do so.
I understand that if I am charged or cautioned criminally after signing this declaration, I must inform The Company immediately. I will inform the Company if I am under investigation or have been suspended by my regulatory body or another employer at any point immediately.
I acknowledge that if there are any changes to my personal particulars I must inform The Company immediately in writing prior to the change coming into effect. This includes any changes to name, address, bank details or gender.
I acknowledge that my personal details will be stored and handled correctly by The Company in accordance with the Data Protection Act 1998.
I give my permission to share any required information from my personnel file with any third party professional that may need to view my details. These details may be required to be made available for audit/review by relevant third party bodies due to compliance and legislative control measures. This is relevant for all information including all documents such as DBS, references and occupational health.
I give my permission for The Company to run a Right to Work check with the Home Office if required. I understand that if I am a student or on a sponsorship visa I can only work a maximum of 20 hours per week. I understand that I have the responsibility to monitor this. In addition if my eligibility to work in the UK position changes I will inform the Company.
I give consent for the completion of an enhances Disclosure and Barring Service application from via eBulk electronic submission, if applicable. I agree that I have represented my true identity and will corroborate my identity to be true via documentation for these purposes.
I acknowledge and confirm that The Company is authorised to apply for and obtain references from any previous employers and educational establishments and agree that these organisations may release my information.
I understand that The Company reserves the right to refuse an application on the grounds of unsatisfactory referencing, training attendance, unsatisfactory conduct whilst undertaking training, undisclosed criminal convictions, unacceptable identity documentation, false work or incorrect address history information.
I am aware that under no circumstances will I apply or accept an invitation of employment or engagement within any company, client, establishment, service user or organisation in which The Company has introduced me to. I am aware that if I want to work within an organisation that The Company has introduced me to I will follow company procedure which starts with informing my line manager.
I understand that my data may be used by The Company for marketing and advertisement purposes such as mailshots. I understand that the data will not be sold or made available to any third-party and that the data will not be used for any purpose that contravenes the Data Protection Act as in force at the time.
I declare that the information given herein is, to the best of my knowledge, true, complete and accurate in all respects and not presented in any way to mislead. I understand that knowingly giving false information will disqualify me from work with The Company. I agree that if I have given misleading information now or in the future, that The Company may cease to offer me work without notice.
I agree to the stated terms and conditions of application and fully understand and agree with all stated terms as listed above. Name Date
