Online Application – Amflo Care Services

Application Form

Step 1 of 7

POSITION APPLIED FOR:

A: PERSONAL DETAILS

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone

Mobile

Date of Birth:

PIN Number: (Qualified Nurse Only)

RIGHT TO WORK:

Are you currently permitted to work in the UK?

VACANCY:

DISCLOSURE & BARRING SERVICE (DBS):

Do you currently have a DBS on the DBS Update Service?

If YES, what is the DBS Update Service reference number

If NO, do you agree to submit fees, in advance, for the DBS disclosure?

B: NEXT OF KIN

Name

First

Last

Telephone

Relationship

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

H: REFERENCES

Please provide details of 2 referees who we may approach with regards to this Job Application. These referees must not be members of your family, and one must be your present or most recent employer:

Reference One

Full Names

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Capacity in which known.

Reference Two

Full Names

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Can we take references at any time?

CONFIDENTIALITY AND DATA PROTECTION

Applicant's Declaration

By signing below, I acknowledge to have read and understood all the clauses specified above and signify my compliance to all the clauses specified herein above. In the event of violation of any of the clauses specified above the patient has the right to take appropriate action against me.

Disease? Only)

I confirm that the information given above is complete and correct. I understand that any incomplete, untrue or misleading information given will entitle the employer to reject my application, withdraw any offer of employment, or, if I am employed, dismiss me without notice.

By my signature, I give authority to the employer to contact my GP for further details regarding any of the potential health problems I have declared above.

I do not wish to complete the questionnaire and I do not wish to have a free health assessment.

Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?

Employment History Gaps:

If you have any gaps in your employment history, please provide a brief explanation of what you were doing and how it has prepared you for this role.

Employment History Gaps:

Signature

Prefix

Name

First

Last

Date / Time

info@amflocareservices.co.uk &nbsp Suite 4 First Floor, Waltham House, Riverview Road Beverley, East Yorkshire, HU17 8DY

01482 818599

Application Form

A: PERSONAL DETAILS

RIGHT TO WORK:

VACANCY:

DISCLOSURE & BARRING SERVICE (DBS):

B: NEXT OF KIN

C: EDUCATION & PROFESSIONAL TRAINING

Examinations, Qualifications

Training Courses

Professional Memberships / Registrations

D: ADDITIONAL QUESTIONS

E: BANK DETAILS

F: EMPLOYMENT HISTORY

Current / Most recent employer

G: JOB FLEXIBILITY

H: REFERENCES

Reference One

Reference Two

I: REHABILITATION OF OFFENDERS

J: DECLARATION BY JOB APPLICANT

EQUALITY AND DIVERSITY MONITORING FORM

Ethnic Origin:

CONFIDENTIAL MEDICAL DECLARATION

A: Do you have, or have you ever suffered from, the following condition:

CONFIDENTIALITY AND DATA PROTECTION

Applicant's Declaration

Employment History Gaps:

Signature