Registration Registration Fill in the form below for your registration Please enable JavaScript in your browser to complete this form.1Personal Information2Additional Information3Education4Employment History5References6Confidentiality Declaration7Rehabilitation of Offenders Act8DBS and Barring Checks9Personal Declaration10Health screening11GDPR Consent FormName *FirstLastDate of Birth *Email *Address *National Insurance NumberNMC PIN (if applicable)Professional Indemnity Professional Organization (RCN, UNISON etc) Membership Details (if any) *NOK Name *Relationship to you *Address *Post Code *NextHave you ever been employed by this organization in the past? YesNoI certify that I am a UK citizen, permanent resident, or a foreign national with authorization to work in the United Kingdom. YesNoHave you ever been disciplined by a professional body (NMC etc)? If Yes, please explain:YesNoDriving License No. *PreviousNextSchool/College/University *Location (mailing address) *Grade *Year & Degree/Diploma *Name of School/College/University *Location (mailing address) *Grade *Year & Degree/Diploma *PreviousNextName and Address of Employeer *Position Held and Summary *FromToReason For Leaving *PreviousNextName Address and Postal Code *Phone *Email *Position *May we contact the above person now? YesNoName Address and Postal Code (2nd) *Phone *Email *Position *May we contact the above person now? YesNoPreviousNextRegistration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about our clients. On no account must information relating to identifiable client be divulged to anyone other than the manager. You should not disclose ANY information to your family, friends or neighbors. If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER. Failure to observe these rules will be regarded as serious misconduct which could result in disciplinary dismissal. I have read and I understand the above and I agree to abide by the contents therein.YesNoPreviousNextIf yes, please provide details of any convictions which are not spent under the terms of the Rehabilitation of Offenders Act 1974. This information will be treated as confidential and will not necessarily preclude you from employment.DBS DISCLAIMER A Disclosure and Barring Service check is necessary for the position you are applying for. Should you be successful in your application, you will be asked to sign a DBS disclaimer. This will be explained, in full, prior to signing the form. Rehabilitation of Offenders Act 1974 – Notice to Offenders Because of the nature of the work involved, the post for which you are applying is exempt from Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act (Exemption Order 1975). This means that you are not entitled to withhold information relating to any convictions you may have had.YesNoPreviousNextDo you have an Enhanced Disclosure from the Criminal Records Bureau (CRB) now known as Disclosure Baring Services? If yes provide DBS certificate number: Have you subscribed for the ‘DBS Update Service’? Circle PleaseYesNoPreviousNextI agree that GB CARE Services 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 General Data Protection Regulations (GDPR). I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated. I declare that the information given is correct to the best of my knowledge. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references. *PreviousNextName *S Code *Account No *Is it Business Account?YesNoBusiness Account Name *PreviousNextTitle *Surname *First Names *Phone Number: *Home Address: *GP Address: *Do you have any illness/impairment/disability (physical or psychological) which may affect your work?YesNoHave you ever had any illness/impairment/disability which may have been caused or made worse by your work? YesNoAre you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide further details of the condition, treatment and dates YesNoDo you think you may need any adjustments or assistance to help you to do the job? YesNoIf you have indicated yes to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned/rejected. TB DECLARATION: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006) Have you lived continuously in the UK for the last year (Include Holidays/ Vacations) YesNoHave you had a BCG vaccination in relation to Tuberculosis? YesNoIf you answered yes please state when A cough which has lasted for more than 3 weeks YesNoUnexplained weight loss YesNoUnexplained fever YesNoHave you had tuberculosis (TB) or been in recent contact with open TB YesNoTriple vaccination as a child (Diphtheria / Tetanus / Whooping cough) YesNoDatePolio YesNoDate Tetanus YesNoDate Course *Boosters *ExemptYesNoCovid 19 First Dose DateCovid 19 Second Dose DateBooster Dose Date I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for the Healthier Business UK Ltd to make recommendations to my employer. YesNoSubmit To find out how we can help you Find an office
