1.Your details

Email address *

First Name *

Last Name *

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Date Of Birth *

National insurance number *

Adress *

POSTCODE *

Phone Number *

Country of birth *

Nationality *

Next of kin *

Relationship to next of kin *

Next of kin's contact number *

2.Job role

Position applied for

NMC number

NMC number expiry date

3.Professional qualifications and experience

Highest qualification

What is the highest qualification you've achieved? *

Name of school/college/university *

Name of qualification obtained *

Date qualification was obtained *

Training

Name of last training course completed *

Name of training body course was obtained from *

Date course was completed *

I am willing to attend mandatory training/specialist training as and when required *

yes

no

4.Employment history

Please add details of the past five years work history, starting with your current or most recently held position. You must state reasons for any breaks in employment.

Position 1

Name of employer *

Address of employer *

Position held and duties *

Start date *

Leaving date *

Reason for leaving *

If there's a gap between this employment role and the one below, please explain why here.

Position 2

Name of employer

Address of employer

Position held and duties

Start date

Leaving date

Reason for leaving

If there's a gap between this employment role and the one below, please explain why here.

Position 3

Name of employer

Address of employer

Position held and duties

Start date

Leaving date

Reason for leaving

If there's a gap between this employment role and the one below, please explain why here.

Position 4

Name of employer

Address of employer

Position held and duties

Start date

Leaving date

Reason for leaving

If there's a gap between this employment role and the one below, please explain why here.

Position 5

Name of employer

Address of employer

Position held and duties

Start date

Leaving date

Reason for leaving

5.Work preferences

To enable us to place you in suitable environments, please indicate areas of choice and speciality.

Please check to indicate your shift preference *

Day shift

Night shift

Full time

Part time

6.References

Please supply names and contact addresses of at least two referees who are healthcare professionals and preferably hold a position more senior to your own.

One referee must be from your current or most recent place of employment.

Reference 1 details

Name of current or most recent employer *

Contact name of line manager for reference *

Professional email address of line manager for reference *

Position held *

Date started *

Leaving date *

Reason for leaving *

Reference 2 details

Name of current or most recent employer

Contact name of line manager for reference

Professional email address of line manager for reference

Position held

Date started

Leaving date

Reason for leaving

Reference 3 details

Name of current or most recent employer

Contact name of line manager for reference

Professional email address of line manager for reference

Position held

Date started

Leaving date

Reason for leaving

7.BANK DETAILS

Please provide PAYMENT DETAILS where you'd like to receive payment for your shifts.

UTR Number (If applicable for self employed)

Company Name (If applicable for LTD)

Company Number (If applicable for LTD)

Name of Account Holder *

Account number *

Sort Code *

Name of bank *

8.Eligibility to work

Before you can work with TotalPro Nurses, we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK in accordance with Home Office guidance on the prevention of illegal working. Please pick ONE of the following option.

Do you have permission to work in the U.K? *

I DO have permission to work in the UK

I do NOT have permission to work in the UK

9.Rehabilitation offenders act

Please read the following statement:

"Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act, 1974, by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986.

Applicants are, therefore, obliged to disclose information about any convictions which for other purposes would be regarded as ‘spent’ under the provisions of the Act”. Failure to disclose such convictions could result in dismissal or disciplinary action by the employing organisation. Any information given will be confidential and will be considered only in relation to any post to which the conviction applies.

Have you at any time received or had pending a court conviction in the UK or overseas? If yes, please give details. *

yes

no

If yes, please give details

Are you aware of any police enquiries undertaken following allegations made against you, in the UK or overseas? *

yes

no

If yes, please give details

10.Data Protection Act statement

We will process all data in compliance with the provisions of the Data Protection Act 1998. Please sign below to freely give your explicit consent to allow the information, given on this form, to be processed in accordance with TotalPro Nurses's registration under the Data Protection Act 1998 for HR and payroll purposes, equal opportunities monitoring and to fulfil statutory requirements, including but not limited to Equalities Act 2010.

Please tick once you have read and understood the above Data Protection Act statement. *

I have read and I understood the above and I agree to abide by the contents therein

11.Confidentiality statement

Registration implies acceptance of our code of confidentiality.

In the course duties undertaken, I may have access to confidentiality information about Clients. Under no circumstances must information relating to identifiable Client be divulged to anyone other than the manager of the agency, or bodies concerned with the welfare of individuals under the governance of the law. I will not disclose ANY information to my family, friends, or neighbours. If you are worried by any information you have obtained and consider that an individual is at risk, please notify your account manager and line manager on the shift immediately.

Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency platform.

Please tick once you have read and understood the above confidentiality statement. *

I have read and I understood the above and I agree to abide by the contents therein

12.Working time regulations

The Working Time Regulations 1998 state that you are unable to work in excess of an average of 48 hours per week (calculated over a 17 week period) unless agreed with TotalPro Nurses that this limit should not apply.

For the avoidance of doubt and for the purposes of the Regulations, the Agency Workers working time shall only consist of those periods during which she/he carries out activities or duties for the Client as part of an Assignment. Time spent travelling to the Client's premises; meal breaks and other rest breaks shall not count as part of the working time for these purposes.

Please select only ONE of the following options

I hereby agree that the 48 hour per week Working Week limit SHALL NOT apply to you

I confirm I do not wish to work an average of more than 48 hours per week in any 17-week period

13. Equal opportunities statement

Equal opportunity for all work seekers is of paramount importance at TotalPro Nurses. As such, TotalPro Nursesis committed to a policy of equal opportunity, and shall adhere to non discriminatory practices at all times on all aspects of operation including recruitment and placement, and to unlawful or undesirable discrimination. Every worker will be treated equally regardless of race, ethnic or national origin, colour, sex, sexual orientation, disability, marital status, age, religion, political beliefs, offending history or membership or non-membership of a trade union and we require commitment from all staff and agency workers to respect and act in accordance with the policy.

Assessment of candidates will solely be based upon the candidates merits, qualification and ability to perform the relevant duties required by a particular vacancy.

Please tick once you have Read and Understood the above Equal Opportunities Statement. *

I have read and I understood the above and I agree to abide by the contents therein.

Do you consider yourself to have a disability under the Equality Act?

yes

no

*The definition of disability according to the Equality Act 2010 is: "A physical or mental impairment which has a substantial and long term adverse effect on his or her ability to carry out normal day to day activities". A long term effect is one that has lasted 12 months, is likely to last 12 months or, is likely to last the rest of the person’s life.

If yes, please provide additional information.

14. Final Statement and Declaration

I hereby declare to the best of my knowledge that the information given above, including any supporting documents is true and correct.

I consent to my personal data and profile being forwarded to clients.

I consent to references being passed on to potential employers.

I consent to the processing of personal data, and for any enquiries to be made to confirm all matters concerning my application, and employment such as qualification, dates of employment, experience, Disclosure and Barring Services check, and health checks, and for the release by other people and organisations for that information might be necessary for that purpose.

I understand that false information might lead to your dismissal from the TotalPro Nurses Flex platform.

If during the course of a temporary assignment, the Client wishes to employ me direct, I acknowledge that TotalPro Nurses will be entitled either to charge the client an introduction/transfer fee, or to agree an extension of the hiring period with the Client (after which I may be employed by the Client without further charge being applicable to the Client).

I understand that acceptance on to the TotalPro Nurses Flex platform may only be granted after relevant checks are made, satisfactory references are received and I have attended a Face to Face interview.

I hereby consent to pre-employment screening checks will take place. I consent for such checks to be performed and acknowledgement that any failure to provide accurate information may result in my application not being taken forward.

I consent to a 3rd Party Audit, complete DBS Check, DBS Update Service Checks, to retain DBS on file, to obtain references, to complete PIN Checks, Right to Work and Identity Checks, to complete Training record checks, to complete Occupational Health checks, to complete Qualification Checks, Confirmation of receipt of AWR information (including Day 1 Rights)

Final statement and declaration Please tick once you have Read and Understood the above Statement and Declaration. *

I have read and I understood the above and I agree to abide by the contents therein.*

date *

Application form

Please complete all 15 sections of the form.

Important: this form can’t be saved part-way through: it must be completed and submitted in one sitting.

To complete the form, please have ready to supply:

Your National Insurance number

Bank details for the account you’d like to receive payments to

Employment details for the last five years (name of employers, places of employment, dates of employment)

Contact details for at least two professional references

Proof of your immunisation record (you can get this from your GP or local travel clinic)

Professional qualification details: place of study, name of qualification and dates of study (nurses only)

NMC number and expiry date (nurses only)

1.Your details

2.Job role

3.Professional qualifications and experience

Highest qualification

Training

4.Employment history

Please add details of the past five years work history, starting with your current or most recently held position. You must state reasons for any breaks in employment.

Position 1

Position 2

Position 3

Position 4

Position 5

5.Work preferences

To enable us to place you in suitable environments, please indicate areas of choice and speciality.

6.References

Please supply names and contact addresses of at least two referees who are healthcare professionals and preferably hold a position more senior to your own.

One referee must be from your current or most recent place of employment.

Reference 1 details

Reference 2 details

Reference 3 details

7.BANK DETAILS

Please provide PAYMENT DETAILS where you'd like to receive payment for your shifts.

8.Eligibility to work

Before you can work with TotalPro Nurses, we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK in accordance with Home Office guidance on the prevention of illegal working. Please pick ONE of the following option.

9.Rehabilitation offenders act

Please read the following statement:

10.Data Protection Act statement

11.Confidentiality statement

Registration implies acceptance of our code of confidentiality.

12.Working time regulations

The Working Time Regulations 1998 state that you are unable to work in excess of an average of 48 hours per week (calculated over a 17 week period) unless agreed with TotalPro Nurses that this limit should not apply.

13. Equal opportunities statement

14. Final Statement and Declaration

15. Health self declaration

As a health care worker, you are under ethical and legal duties to protect the health and safety of the individuals in your care. All information disclosed will be processed in accordance with the requirements of the Data Protection Act.

Please provide proof of your immunisation record This can be obtained from your GP or local travel clinic.

Don’t hesitate to give us a call.