Application Form | NextGen Healthcare Services

Application Details

Position Applied For *

Your Full Name *

1. Personal Details

Title

Surname *

Forenames *

Maiden Name

Previous Surnames

Nationality

Address *

Date of Birth

National Insurance Number

Home Telephone

Work Telephone

Mobile *

Email Address *

May we contact you at work?

Yes No

Next of Kin / Emergency Contact Name

Relationship to You

Next of Kin Address

Next of Kin Home Telephone

Next of Kin Work Telephone

Next of Kin Mobile

Which of the following applies to you?

Registered Nurse Support Worker (Agency) Support Worker (Care at Home)

NMC PIN Number

SSSC Registration Number, if applicable

Upload Current CV

Please upload your CV showing professional qualifications and full employment history for the last 10 years, including any gaps.

2. General Information

Do you hold a valid and current British driving licence?

Yes No

If yes, what type?

Do you have any endorsements?

If yes, please give details

Please state which languages you speak, including fluency level

Will you use your own car for commuting to work?

Yes No

Upload Business Car Insurance, if applicable

If claiming mileage expenses, please submit a copy of your business car insurance.

How did you hear about this agency?

Are you a member of a union or professional organisation offering indemnity insurance?

Body / Organisation Name

Amount of Cover

Policy Number

Expiry Date

3. Preferences Regarding Work

Position Type

Part-time Full-time

Type of Work

NHS Private Hospitals Care Home Care at Home Support Services

Other, please specify

Availability

Live-in Days Nights Visits

Do you have any other work commitments?

When will you be available to start work?

Which areas of work do you wish to exclude?

Additional Notes

4. Working Time Directive

The Working Time Regulations set limits on weekly working hours. Because you are under no obligation to accept work offered, you will never be compelled to work more than 48 hours per week.

I do not wish to work more than 48 hours per week

Yes No

5. Immunisations

Please submit a copy of your childhood and most recent immunisation records. If you wish to work NHS shifts, this should include proof of BCG, MMR and Hepatitis B immunisations where required.

Upload Immunisation Record

6. References

Please provide two work-related referees. One referee should be your current employer, or if you are unemployed or self-employed, your most recent employer.

Referee 1

Name

Address

Postcode

Telephone

Email

Position

Relationship to You

May we contact Referee 1 now?

Referee 2

Name

Address

Postcode

Telephone

Email

Position

Relationship to You

May we contact Referee 2 now?

7. Confidentiality Declaration

During your duties you may have access to confidential information about clients and colleagues. Information relating to an identifiable client must not be disclosed to anyone other than your line manager or another authorised person at NextGen Healthcare Services Ltd.

I have read and understood the confidentiality declaration and agree to comply with it. *

8. Data Protection and Audit Permission

I give permission for authorised auditors to audit my personal file during an inspection or audit.

I give permission for NextGen Healthcare Services Ltd to use my photograph on its website or official social media pages.

9. Right to Work in the UK

Are you eligible to work in the UK? *

Upload Right to Work Document

10. Rehabilitation of Offenders Act

Please tick one *

If you have convictions to disclose, please provide details

11. Criminal Records - Self-Disclosure

I have never been cautioned by the police or convicted of any criminal offence.

I have a police record as follows

I have been questioned by police, arrested or charged with a criminal offence as follows

12. Personal Declaration

I declare that, to the best of my knowledge, the information provided in this form and all accompanying documents is correct. I give permission for checks to be completed for recruitment and employment purposes.

I agree to the personal declaration above. *

Applicant Full Name / Signature *

Date *

Upload Additional Document, if required