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Personal Details

Title

First Name

Known As

Middle Name

Last Name

Maiden Name

Gender

Date Of Birth

Nationality

Work Status

Self Employed or PAYE:

National Insurance No:

Passport No:

Passport Expiry Date:

Address

Town/City:

County:

Postcode:

Date moved to address:

Email:

Tel: Home:

Tel: Mobile:

How Did You Hear Of Us:

Driving License:

Yes

Car Owner:

Yes

We are open 24 hours a day, Please specify times at which you are not to be contacted below.

Contact Availability:

Is it Ok to contact you at work:

Yes

Career History
Please confirm your career history details for the last 5 years. Please list using most recent first.

Employer

Address

Phone

Start Date:

Job title:

Grade:

Date Left:

Full or Part Time:

Dept/Ward:

Reason for leaving:

Career History
Please confirm your career history details for the last 5 years. Please list using most recent first.

Employer

Address

Phone

Start Date:

Job title:

Grade:

Date Left:

Full or Part Time:

Dept/Ward:

Reason for leaving:

Qualifications & Training

Date Qualified:

NMC Pin Number:

Expiry Date:

Where did you train?

Please give details of training undertaken and qualifications obtained:

You should supply any certificates such as ENB or Diplomas etc -please note that we require manual handling/CPR certifications that have been updated in the last 12 months.

Recordable Qualifications

Medical History
Have you ever suffered from any of the following:

Are you taking any prescription drugs?

Yes

If you have answered yes to any of the above questions please give details below:

Have you ever been vaccinated, immunized or tested for/against any of the Following?

Tetanus:

Yes

Typhoid:

Yes

Any Other Please State:

Name of GP:

Address:

Post Code

Telephone

References
Glory Crown requires 2 professional references. It is essential that you have had professional dealings with both of your references within the last 2 years.

Name Of Referee:

Work Address:

Country:

Postcode:

Name Of Referee:

Work Address:

Country:

Postcode:

Place Of Work:

Position:

Phone:

Fax:

Email:

Mobile Phone:

Place Of Work:

Position:

Phone:

Fax:

Email:

Mobile Phone:

OPT Out Agreement

DEFINITIONS

In this Agreement the following definitions apply:-
“Assignment” means the period during which the Temporary Worker is engaged in services to a Client.
“Client” means the person, firm or corporate body that has engaged the services of the Temporary Worker.
“Employment Business” means Glory Crown.
“Temporary Worker” means a Qualified Nurse, care assistant or other Temporary Worker.
“Working Week” means an average of 48 hours each week as calculated over any 17 week period.

THE AGREEMENT

The Working Time Regulations of 1998 state that a Temporary Worker shall not work on an Assignment with a client in excess of the Working Week unless they agree in writing that this limit should not apply.
The Temporary worker, by signing the declaration below, agrees that the Working Week shall not apply to their Assignments.
The Temporary Worker can end this Agreement at anytime by giving the Employment Business 14 days notice in writing. After the 14 day notice period has expired the Working Week shall apply immediately.
It should be noted, that any notice ending this Agreement does not mean that a Temporary Worker has ended an Assignment with a Client.
These laws are governed by English Law and are subject to the jurisdiction of the English Courts.

THE DECLARATION

I have read and fully understand the above OPT OUT AGREEMENT.
I hereby consent that the Working Week limit shall not apply to my Assignments.
I understand that I can end this Agreement by giving the Employment Business 14 days notice in writing.

I Agree

Yes

Date Confirmed

Next of Kin Details

Full Name:

Relationship:

Phone:

Address:

Other Special Notes:

Disclosures
Rehabilitation of Offenders Act

Due to the nature of the work for which you are applying, this post is exempt from the provisions of section 4.2 of the rehabilitations of offender’s act 1974 (exemption order 1975). Applicants are therefore, not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the act and in the event of employment. Failure to disclose such convictions could result in dismissal or disciplinary action.

Any information given will be completely confidential and will be considered only in elation to an application for positions in which the order applies, and should be entered at the end of any particulars you give in support of your application.

A copy of our written policies is available upon request. A criminal record will not necessary be a bar to obtaining a position.

Do you have any spent or unspent criminal convictions or cautions?

Yes

Have you ever been convicted of a criminal offence?

Yes

With an enhanced disclosure, under section 4.2 of the rehabilitation of offenders act 1974 (exemption order), all previous cautions, warnings and convictions will always be detailed regardless of how long ago.

Any conviction, caution, reprimand will require a written statement of each and every event and how it does not affect your suitability for the role you are applying for.

Have you supplied additional information with this application for any spent/ unspent convictions, cautions or reprimands?

Yes

Have you ever been involved in court proceedings?

Yes

Please give any additional information which you think may be relevant in support of your application :

IF YOU HAVE A CONVICTION/CAUTION RELATING TO A VIOLENCE OR THEFT OFFENCE, WE WILL BE UNABLE TO PROGRESS WITH YOUR APPLICATION.

Declaration
I confirm that the information I have provided in support of this application is complete and true and understand that knowingly to make a false statement could be a criminal offence.

Name

Date

I consent to Glory Crwonchecking the details I have provided against the various data sources in order to verify my identity and process the application. These details may be recorded and used to assist other organisations for identity verification purposes such as the CRB, regulatory bodies such as NMC or GSCC.

Name

Date

Glory Crown retains the right to hold this application and any other data required to process this application (whether in the UK, European Union or elsewhere) and keep for as long as necessary in line with the data protection act.

Additional Information/Checklist

On receipt of a satisfactorily completed application form, Glory Crown will provide/send the following:-
1. Assist you with your DBS application for an enhanced DBS. The charge for this will be £44.00 (cheques to be made payable to Glory Crown Ltd).

Please tick boxes:

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