Register

Application Form

First Name *

Last Name *

Phone Number *

Date of Birth *

Email *

Address *

City *

Post Code *

National Insurance Number *

Place of Birth (city/country) *

Next of Kin (name, relationship, phone) *

ID Badge Colour photo ID Badge *

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GP Details Name of GP Surgery *

References

Please use this section to provide a list of two professional references.

Referee 1 Name, Grade/Band, Organization and Professional Email *

Referee 2 Name, Grade/Band, Organization and Professional Email *

Please upload your CV *

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Criminal Record

Due to the nature of the posts within St Clair Healthcare, they may be exempt from the Rehabilitation of Offenders Act 1974 (exception Orders 1975). If the post applied for requires a Disclosure as indicated on the frontpage, you should disclose information of all spent and unspent convictions as well as details of any cautions, reprimands, or final warnings in the UK or/ and abroad.

Do you have any criminal convictions or are you currently the subject of any police investigation in the UK or abroad? *YesNo

Are you currently the subject of any investigation or proceeding by anybody having regulatory functions in relation to health and social care professionals including a regulatory body abroad? *YesNo

Have you ever been disqualified from the practice of a profession or required to practice it subject to specified limitations following a fitness to practice investigation by regulatory body abroad? *YesNo

Data Protection – GDPR Consent

I certify to St Clair Healthcare that the information is true and complete to the best of my knowledge, and I consent St Clair Healthcare in processing personal data about me for purposes related to my employment in line with the DATA PROTECTION ACT, 1998. If this application leads to employment, I understand that false or misleading information in my application or interview may result in may result in termination of employment.

I understand and agree

Do you consent for us using your personal information i.e., your email address to send you emails regarding shift availability?
Do you consent for us using your personal information i.e., your email address to send you marketing emails?
Do you consent for us using your personal information i.e., your email address to send you compliance updates?
Do you consent for us using your personal information i.e., your email address for training updates?
Do you consent for us using your personal information i.e., your telephone number to send you a text messages regarding available shifts?
Do you consent for us using your personal information i.e., your telephone number to call you regarding available shifts?
Do you consent for us using your personal information i.e., your telephone number to send you marketing text messages?
Do you consent for us using your personal information i.e., your telephone number to send you compliance updates?
Do you consent for us using your personal information i.e., your telephone number to call you regarding training updates?
Do you consent for us using your personal information i.e., your bank details to be used within our payroll department to process your pay?
Do you consent for us using your personal information where necessary i.e., when working with vulnerable groups to be sent U-Check to obtain a DBS/CRB?
Do you consent us to saving a hard copy of your DBS/CRB?
Do you consent us to applying for a DBS/CRB via U-Check on your behalf when necessary?
Do you consent for us sending your personal information such as immunizations to Healthier Business to conduct a Fitness to Work on an annual basis?
Do you consent for us to approach external certificate issuers to verify training on your behalf?
Do you consent for us to conduct weekly NMC Pin checks?
Do you consent for us to do a Home office check on your Right to work when necessary?
Do you consent for us to send your personal information on to hospital trusts?
Do you consent for us to send your personal information to NHS Staff Banks?
Do you consent to us contacting your previous employers to obt in references?
Do you consent for your personal file to be reviewed and audited by an external auditor when to company is due on audit?
Do you consent for us to process your occupational health reco ds to access your suitability for work?
Do you consent for us to send your occupational health records to prospective clients/ employers so they can assess your suitability for their jobs?

I understand and agree *YesNo

Company Agreements

Opt – Out 48 hour Working Week Agreement

For the Working Time Regulations 1998, I consent to work more than an average of 48 hours per week. I understand that I may withdraw this consent by giving St Clair Healthcare not less than one months’ notice. I understand that my registration with St Clair Healthcare can be terminated at any time following unsatisfactory work reports.

I consent to workI don’t consent to work

Bank details

I have completed my bank details and confirm they are complete and correct. I hereby understand that any in corrector incomplete details can result in a delay of my payment. *YesNo

Compliance Updates

Data Protection Many of your compliance items need to be reviewed annually. It is your responsibility to ensure that your file is always in date. If any of your compliance items lapse, it may cause the suspension and/or termination of your placement.

I agree that St Clair Healthcare retain the right to hold this application and any other data required to process it and to pass on to any authorized third party the details held within, also to retain these details for as long as reasonably necessary in accordance with the Data Protection Act

select appropriately *YesNo

Terms and Conditions

I confirm that the information given in this application is, to the best of my knowledge, true. I am permitted to work in the UK.

I understand that my registration is subject to the receipt of at least two satisfactory references and an enhanced disclosure from the Disclosure and Barring Service (DBS).

I undertake to inform St Clair Healthcare should I be convicted of an offence in the future.

I undertake to inform St Clair Healthcare immediately if I am engaged through their introduction, including the offer of permanent employment following a temporary assignment.

I am clear that St Clair Healthcare cannot guarantee assignments and that they have no responsibility to pay for hours did not work no matter the situation.

I can confirm I have read, understood, and agree to the conditions of work for temporary nurses, of which I have been given a copy. *YesNo

The St Clair Healthcare consultant you spoke with? *

Full Name *

Dated *

Signed *