Please state your last 5 years of employment history (current or most recent first). Information must cover the whole of your working life to date. State the reasons for any breaks in employment. Use a separate attached sheet if required; please sign that sheet(s).
Note: Minimum age legislation dictates that Care workers must be 16 years old or older. Please inform your interviewer immediately if you do not meet these specifications. You must provide references from your two most recent employers. Please provide an additional character referee. All will be contacted with your consent, therefore please inform the referees. If you are unable to provide the required references, please discuss the matter with us.
Any offer of employment may be made subject to a satisfactory medical report.
Minimum age legislation dictates that Care workers must be 16 years old or older. Please inform your interviewer immediately if you do not meet these specifications
The position you have applied for is exempt from the Rehabilitation of Offenders Act 1974 (as amended in England and Wales).
When ELMS Health Solutions is assessing your character and suitability for any such appointment, it is legally permitted to ask for and consider any information relating to unspent (current) and spent (old) criminal convictions, police cautions, final warnings or reprimands which are not protected (or filtered out) by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013. # Any information you declare when completing this form will be verified by undertaking a follow-up check with the relevant body. It will also include carrying out a standard or enhanced disclosure through the Disclosure and Barring Services (known as a DBS check).
I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately. I understand that I may not be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS.
I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise ELMS Health Solutions Ltd to request a DBS Register check and a criminal record check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred Care workers, or withdrawal of any registration required by my employment status.
ELMS Health Solutions offers work and appoints employees based on merit and does not discriminate unfairly in recruitment or any other treatment. Any information that you provide on this form is strictly confidential and is for monitoring purposes only (it will not be used as part of the selection process).
Please tick the most appropriate box below
The Equality Act 2010 defines a disability as a "physical or mental impairment which has a substantial and long- term adverse effect on a person's ability to carry out normal day-to-day activities". An effect is long-term if it has lasted, or is likely to last, more than 12 months.
The Disability Discrimination Act 1995 (DDA) defines a disability as “A physical or mental impairment which has substantial and long-term adverse effect on a person’s ability to carry out normal day to day activities”. (In such cases long term is regarded as more than 12 months). Anyone who is diagnosed with HIV, cancer or Multiple Sclerosis is immediately treated as disabled under the DDA. We do not discriminate based on the grounds of a person’s disability and we are strongly committed to providing appropriate support for staff/students with disabilities.
Without knowledge of your disability, it may be difficult to fully provide support for your needs and make the necessary adjustments. Information disclosed by the applicant regarding your disability and/or additional needs will be handled with the strictest confidentiality.
1. HEALTH CARE WORKER “Assignment” means the period during which the Agency Worker is supplied to provide services to the Client; “Client” means the person, firm or corporate body using the services of the Health Care Worker; “Employment Business” means Elms Health Solutions Limited, of; 1010 Cambourne Business Park, Cambourne, Cambridge, Cambridgeshire CB23 6DP “Working Week” means an average of 48 hours each week calculated over a 17week reference period. 1.1. References to the singular include the plural and references to the masculine include the feminine and vice versa. 1.2. The headings contained in this Agreement are for convenience only and do not affect their interpretation.
2. RESTRICTION The Working Time Regulations 1998 (as amended) provide that the Health Care Worker shall not work on an Assignment with the Client in excess of the Working Week unless s/he agrees in writing that this limit should not apply.
3. CONSENT The Health Care Worker hereby agrees that the Working Week limit shall not apply to the Assignment.
4. WITHDRAWAL OF CONSENT 4.1. The Health Care Worker may end this Agreement by giving the Employment Business three months’ notice in writing. 4.2. For the avoidance of doubt, any notice bringing this Agreement to an end shall not be construed as termination by the Health Care Worker of an Assignment with a Client. 4.3. Upon the expiry of the notice period set out in clause 4.1 the Working Week limit shall apply with immediate effect.
5. THE LAW This Agreement is governed by the law of England & Wales and is subject to the exclusive jurisdiction of the Courts of England & Wales.
1.0 I accept that the Service holds personal data about me and I hereby consent to the processing by the Service or any associated company of my personal data for any purpose related to the performance of my contract of employment or my continuing employment or its termination or the conduct of the Service’s business, including, but not limited to, payroll, human resources and business continuity planning purposes.
2.0 I also explicitly consent to the Service or any associated organisation processing any sensitive personal data relating to me, for example sickness absence records, medical reports, particular health needs, details of criminal convictions and equal opportunities monitoring data, as necessary for the performance of my contract of employment or my continuing employment or its termination or the conduct of the Service’s business.
3.0 Finally, I consent to the Service providing my personal data to a third party where this is necessary for the performance of my contract of employment or my continuing employment or its termination or the conduct of the Service’s business, for example to a pension scheme provider in relation to my membership of a pension scheme or to an insurance company in relation to the provision of insured benefits.
