Join Us – Candela Healthcare

Registration form

Post applying for?

First Name *

Middle Name

Last Name *

Address *

City

County

Postal Code

Phone *

Email Address *

National Insurance Details:

N.I. number

Do you have the right to work in the UK? *

YesNo

Please provide details of your visa and any restrictions in the space provided below (if applicable)

Do you drive a car?

YesNo

Are you happy to drive to work?

YesNo

Next of Kin.( For emergency contact)

Full Name *

Relationship

Next of Kin Tel

Next of Kin Address

Next of Kin Mobile *

Next of Kin Email *

Full Employment History

Please list below your complete and full employment history, explaining all employment gaps, starting with your most recent employer, working backwards to when you left full-time education (continue on a separate sheet if necessary).

Upload your latest CV (if possible)

No file chosen

Employer 1

Company Name

Reference details *

Position

Address

Email *

Tel

Job title and main duties *

Start date

End date

Choose today's date if you are still with this employer.

Notice period *

Reasons for leaving?Please state if you are still with the same employer

Employer 2

Company name

Reference details. *

Position

Address

Email *

Tel

Job title and main duties *

Start date

End date

Notice period *

Reasons for leaving?

Employer 3

Company name

Reference details.

Position

Tel

Job title and main duties

Start date

End date

Notice period

Address

Reasons for leaving?

Education and professional qualifications:

Secondary School name and address *

Qualification gained *

Start date

End date

Further Education

Further education. E.g. College/University *

Qualification gained *

Start date

End date

Please provide details of any extra qualifications below.

Courses and Training (Most recent first)

Please list/provide details of your training and courses attendedPlease enter the names and dates of the courses and training attended starting with the most recent .

Are you undertaking any course of study at present? *

YesNo

Professional Body Membership

Registration number ( NMC) if applicable

Expiry/Renewal Date

Character references

Please provide details of two people who can be contacted for a reference if you have not provided a full 5 year work history. The referee must be able to comment on your suitability and character for the post you have applied for (e.g. fellow work colleague or course tutor). Relatives and/or Partners should not act as referees. Referees will not be contacted without your consent.

Character Reference 1

Contact Name

Job Title

Address

Tel

Relationship to you

Number of years known

Character reference 2

Contact Name

Job Title

Address

Tel

Relationship to you

Number of years known

EQUAL OPPORTUNITY MONITORING FORM

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 property 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 oportunity.

Please Tick The Relevant Box

WhiteMixedAsianBlackChineseOther

Gender

MaleFemale

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

16-2122-2526-3031-3536-4041-4546-5051-6060-65

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

YesNo

If yes, give details

Disclosure of criminal record information

Due to 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 1974 (Exceptions) Order 1975. This means that convictions that are ‘spent’ under the terms of the Rehabilitation of Offenders Act 1974 must be disclosed and will be taken into account in deciding whether to make an appointment. Applicants are therefore not entitled to withhold information about convictions, which for other purposes are spent under the provisions of the act and in the event of employment any failure to disclose such convictions could result in dismissal or disciplinary action by the employer. All Successful candidates will be required to obtain an enhanced disclosure report from the Disclosure and Barring Service. .Any information will be completely confidential and will be considered only in relation to this application. Have you ever been convicted of a criminal offence, or been subject to any confidential discharge, bind-overs or cautions.? *

YesNo

Have you ever been convicted of any criminal offence? *

YesNo

If yes to question above, please give details.

Have you ever received any official cautions, reprimands or warnings? *

YesNo

If yes to question above, please give details.

To your knowledge, are you currently the subject of any criminal proceedings or any police investigation? *

YesNo

If no please sign the declaration below. If yes to any of these questions above, please give details.

I declare that I do not possess, nor have I ever possessed a criminal conviction, nor have I been subject to any conditional discharges, bind-overs or cautions

By entering date above I agree to the question above.

Any information contained in this form 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. *

Yes

HEALTH CHECK QUESTIONNAIRE

GP Contact Details *

Please answer the following questions by giving relevant details

Have you ever suffered from any of the following:

Depression, anxiety state, nervous illness or breakdown

yesNo

If Yes

Epilepsy or disease of the nervous system

yesNo

If Yes

Ailment of lungs or chest

yesNo

If Yes

Spinal Problem (backache)

yesNo

If Yes

Arthritis, Rheumatism or Gout etc

yesNo

If Yes

Any heart or circulatory, including blood problems

yesNo

If Yes

Illness of the kidneys, bladder, liver or glands

yesNo

If Yes

Diabetes

yesNo

If Yes

Skin Disorder

yesNo

If Yes

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

Are you a registered disabled person?

YesNo

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

Additional Details: (if necessary)

Notes

Data Protection:

The Candela Healthcare Recruitment Privacy Statement is available on our website (www.candelahealthcare.co.uk) or a copy can be requested from the Human Resources Department. Please sign below to confirm you have accessed the Candela Healthcare Recruitment Privacy Statement and you have read, understood and agree to all the terms stated.

Date *

Name *

DECLARATION

I declare that the information given in this application is to the best of my knowledge, complete and correct. I accept that should any statement made by me in connection with this application be found to be false, incomplete or misleading then the application shall be void and consequently, Candela Healthcare Ltd may terminate any contract arising at any time. Because of the sensitive nature of the duties the postholder will be expected to undertake, I understand that the declaration will include details of any criminal convictions, cautions, reprimands and final warnings that are not ‘protected’ as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013) and any other information that may have a bearing on my suitability for the post. I also understand that the relevant level of DBS check will be sought in the event of a successful application

Name *

Date *

Tick the box to accept out T&C and Privacy policy.

Registration form

National Insurance Details:

Do you have the right to work in the UK? *

Do you drive a car?

Are you happy to drive to work?

Next of Kin.( For emergency contact)

Full Employment History

Employer 1

Employer 2

Employer 3

Education and professional qualifications:

Further Education

Courses and Training (Most recent first)

Are you undertaking any course of study at present? *

Professional Body Membership

Character references

Character Reference 1

Character reference 2

EQUAL OPPORTUNITY MONITORING FORM

Please Tick The Relevant Box

Gender

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

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

Disclosure of criminal record information

Have you ever been convicted of any criminal offence? *

Have you ever received any official cautions, reprimands or warnings? *

To your knowledge, are you currently the subject of any criminal proceedings or any police investigation? *

Any information contained in this form 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. *

HEALTH CHECK QUESTIONNAIRE

Please answer the following questions by giving relevant details

Depression, anxiety state, nervous illness or breakdown

Epilepsy or disease of the nervous system

Ailment of lungs or chest

Spinal Problem (backache)

Arthritis, Rheumatism or Gout etc

Any heart or circulatory, including blood problems

Illness of the kidneys, bladder, liver or glands

Diabetes

Skin Disorder

Are you a registered disabled person?

Data Protection:

DECLARATION

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