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Personal Information
Position applied for:
Approx. no. of hours you can work per week:
Please enter a value between 1 and 100.
Which one you are able to Work?
- Full-time
- Part-time
Which one you are able to Work?
- Live In
- Days
- Nights
Candidates Name
First Name Surname
Date of Birth
Previous surnames
Surname
Supply documentary evidence e.g. marriage certificate, deed of name change etc.:
Drop files here or
Current Address
Street Address Address Line 2 City Post Code Country
Date Moved In:
Telephone number (home):
Telephone number (work - will be used with discretion):
Mobile Number:
Email
DBS Online Number: 001
National Insurance Number:
Do you have your Own Transport?
- Yes
- No
Clean current driving licence
- Yes
- No
How long has your licence been held ?
Please enter a value between 0 and 100.
Endorsements:
- Yes
- No
Endorsements: If yes please describe

Next of Kin
Next of Kin Name
First Name Surname
Address
Street Address Address Line 2 City Post code Country

Education
School/College/University
Examinations Passed/Qualifications Gained
TRAINING HISTORY/PROFESSIONAL COURSES
These must be FACE To FACE CLASS Training not eLearning Courses
All in One Mandatory Care Certificate MUST include (Manual Handling)
Date of Training/Qualification
Location/Details
Medication Certificate
Date of Training/Qualification
Location/Details
Please supply other copies of certificates/membership details
Drop files here or

EMPLOYMENT HISTORY
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.
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.
Company One
Name of Company
Address of Company
Street Address Address Line 2 City Post Code Country
Start Date
Finish Date
Nature of Business
Postion Held
Reason for leaving:
Salary / Rate
Company Two
Name of Company
Address of Company
Street Address Address Line 2 City Post Code Country
Start Date
Finish Date
Nature of Business
Postion Held
Reason for leaving:
Salary / Rate

Employment References
Reference 1
Name
First Last
Address
Street Address Address Line 2 City Post Code Country
Email
Phone
Job Title
Reference 2
Name
First Last
Address
Street Address Address Line 2 City Post Code Country
Email
Phone
Job Title

Character Reference
Name
First Last
Address
Street Address Address Line 2 City Post Code Country

ASSISTANCE WITH INTERVIEW AND ASSESSMENT
Do you require us to make any special arrangements in order for you to participate in the recruitment process?
- Yes
- No
Please provide details
Any offer of employment may be made subject to a satisfactory medical report.
GP's Name
First Name Surname
Telephone Number
Address
Street Address Address Line 2 City Post code Country
Your GP will never be contacted without your permission

RIGHT TO WORK IN THE UK
Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?
- Yes
- No
If you are successful in the application, would you require a work permit prior to taking up employment?
- Yes
- No
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

CRIMINAL RECORD
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).
Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.
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.
- Agree

BANK DETAILS
Bank Name:
Account Number:
Sort Code:

48Hr WORKING TIME OPT OUT
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.*
- Agree

EMPLOYEES PROCESSING OF PERSONAL DATA CONSENT
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.*
- Agree

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Personal Information

Next of Kin

Education

TRAINING HISTORY/PROFESSIONAL COURSES

EMPLOYMENT HISTORY

Company One

Company Two

Employment References

Reference 1

Reference 2

Character Reference

ASSISTANCE WITH INTERVIEW AND ASSESSMENT

RIGHT TO WORK IN THE UK

CRIMINAL RECORD

EQUAL OPPORTUNITIES MONITORING

DISABILITY

HEALTH DECLARATION

BANK DETAILS

48Hr WORKING TIME OPT OUT

EMPLOYEES PROCESSING OF PERSONAL DATA CONSENT

Monday	9am > 5pm
Tuesday	9am > 5pm
Wendsday	9am > 5pm
Thursday	9am > 5pm
Friday	9am > 5pm
Saturday	Call Emergency Contacts
Sunday	Call Emergency Contacts