Application Form Welcome to The Recruitment Agency Where are you applying from? *UKOutside of the UKJob title you are applying for *PrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *Date of Birth *Street AddressApartment, suite, etcCityCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweWhere are you applying from? *National Insurance Number *NationalityEmail Address *Phone number *Do you hold a full & valid driving license for the UK?YesNoAre you eligible to work in the UK?YesNoEmployment HistoryBriefly detail your employment history within the past 5 years, starting with the most recent. Please include the dates, FROM/TO. Detail any employment gaps within this period.Training and EducationWas your mandatory training - for example moving & handling, infection control, safeguarding, medication admin (RNs only) completed within the last year? Briefly outline any qualifications as well as professional & vocational training that you feel are relevant to this jobRelevant Healthcare Training (past 12 months)Option 1Option 2Upload CertificatesChoose FileNo file chosenDelete uploaded fileDBS status. Have you subscribed for the DBS Update Service? Please select.YesNoPrevious ConvictionsPlease give details of any convictions in this country or abroad you currently or have previously had. If none, please write the word “NONE” in this box. Please be aware that it is an offence to withhold this information.ReferencesPlease give details of two people that would be prepared to give you a reference. One must be from a current/previous employer; the other should be a character reference, from someone other than a family member. Any offer of employment will be subject to satisfactory references. By entering their details here, you give Okiri Healthcare Ltd. permission to contact these people. Please include Name, Position, Organisation, Address, Email and Phone NumberHealth and Safety - Do you have a disability of any kind that may affect your work? please select.YesNoPlease give details …Working PreferencesDay ShiftsNight ShiftsWeekdaysWeekendsHow many days/nights per week?OneTwoThreeFourFlexibleHow would you like to be paid?PAYEDirect through UTR or company (Ltd)Account NameName of Bank/Building Society:Account No:Sort CodeOnline data - We keep many of your records securely online. In addition, clients may ask that these are uploaded and shared online with their own client base (e.g. nursing & care homes), prior to the commencement of your first shift with them. Do you authorize that these details can be shared with them online? *YesNoWorking time regulations - the maximum working week is currently limited to 48 hours. As you are under no obligation to accept any work offered, you will not be compelled to work more than 48 hours per week. However, you may choose to do so. Please select.I DO wish to work more than 48 hours per weekI DO NOT wish to work more than 48 hours per weekData Protection Our records, including any copies of documents supplied are kept securely in line with GDPR regulations. You understand & give permission for these to be made available from time to time to authorized personnel or inspectors, Home Office Immigration Check. If applicable, you understand & give permission for Okiri Healthcare Ltd. to contact the appropriate authority in order to verify your current immigration status. Please tick.YesUpload 1 (one) Category A supportive documents: • Current and valid UK Passport. • UK driving license photo card • UK Original Birth Certificate • A UK biometric residence permit cardChoose FileNo file chosenDelete uploaded filePlease upload your CVChoose FileNo file chosenDelete uploaded fileUpload 2 (two) Category B supportive documents: • A Bank or Building Society statement - less than 3 month old. • Utility Bill less than 3 month old. • A Credit Card statement • A Council Tax statement. • A mortgage statement. • A letter from: HMRC, Dept. of Works and Pensions, Jobcentre Plus or any other employment service. • A P45 or P60 statement, A pension or endowment or ISA statement.Choose FileNo file chosenDelete uploaded fileUpload a Passport Style photograph. It must be clear, full face, no hats and against a white background.Choose FileNo file chosenDelete uploaded fileImmunisationsHep B *YesNoTB *YesNoVaricella *YesNoMeasles *YesNoRubella *YesNoHep CNo ProofNegativePositiveHep B AntigenNo ProofNegativePositiveHIVNo ProofNegativePositiveCOVID VaccinationNo ProofNegativePositiveAre you related to a member of staff or service user at Ahead Support Ltd?YesNoName of the staff member or Service UserYour relationship to the staff member or Service UserHEALTH AND SAFETY - Each agency worker has a responsibility at the start of their first shift to become familiar with the Client’s general policies including, without limitation, those relating to Emergency Call Procedures, the Hot Spot Mechanism for alerting security staff that an individual is in trouble, Fire Policy and the Violent Episode Policy.I understandI confirm that I have read and understood the above information and declare that my responses are accurate and correct. Additionally, I understand that: It is my responsibility to notify A Head Support Ltd. if any of these details change in the future. Any job offer made to me is conditional upon obtaining satisfactory references from the referees provided above, and I give permission for A Head Support Ltd. to contact them. If I do not subscribe to the DBS Update Service, Ahead Support Ltd. will arrange a Disclosure and Barring Service (DBS) check upon acceptance and at regular intervals thereafter. I agree to cover the cost of this check, either through deductions from my wages or by direct payment within three months of the DBS request, whichever comes first. A Head Support Ltd. may contact the Home Office/UK immigration to verify my eligibility to work in the UK. If any information provided in this application form is found to be false, it may result in disciplinary action or dismissal.I agreeSend Message
