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We are one of the fastest growing nurses and domiciliary care agency with offices throughout the UK.



Issue Date

Expiry Date

If student, please provide the course details

appoinmentNEXT OF KIN



Plese give the name and contact details of two referees. One should be your previous Employer.

Reference 2


The information on this form will be used in total confidence and accordance with current data protection legislation. It will help to ensure that the company proprty monitors and confirms with its policies relating to equality of opportunity. Information will be used for monitoring only. Our commitment aims to allow our staff to develop their skills and realize their maximum potential as individuals without any wish on the part of the company to limit their opportunity.


Please Indicate your age range by ticking one of the boxes below

Do you consider yourself to have a disability of some kind ?


Has any Social Service Department or Has any Social Service Department or Police Service ever Conducted an equiry or investigation into any allegations or that you may pose an actual or potential risk to children or vulnerable adults?

Have you ever been convicted of any offence relating to children or vulnerable adults?

Have you ever been the subject of any disciplinary procedure or been asked to leave employment or voluntary activity due to inappropriate behaviour towards a child or vulnerable adult?


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(Exemptions) Order 1975. Applicants are therefore not entitled to withhold information about convictions, which for other purposes are spent under the provisions of act and in the event of employment any failure to disclose such convictions could result in dismissal or disciplinary action by the employer. All Successfull candidates will be required to obtain an enhanced disclosure report from the Disclosure and Barring Service.Have you ever been convicted of a criminal offence, or been subject to any confidential discharge, bind overs or caution.

Any information contained in this will be treated in confidence. Failure to disclose any relevant information or providing false or inaccurate information may be regarded as a breach of any subsequent contract of employment, resulting in disciplinary action and/or dismissal.

appoinmentHEALTH CHECK QUESTIONNAIRE (optional/to be filled upon selection)

Please answer all the following questions by giving relevant details

1.Have you ever suffered from any of the following

a) Depression,anxiety state,nervous illness or breakdown

b) Epilepsy or disease of the nervous system

c) Ailment of lungs or chest

d) Spinal problem(backache)

e) Arthritis, Rheumatism or Gout etc

f) Any heart or circulatory, including blood problems

g) Illness of the kidneys, bladder,liver or glands

h) Diabetes

i) Skin disorder

2. Are you presently taking medication or undergoing treatment. If so give details

3. What is your average daily consumption of

5. Details of any industrial disablement benefit received

6. How many working days have you been absent from working during the last 12 months(apart from holidays)

7. Are you now pregnant?

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