We Good Care Ltd

20 Bridge Road,Haywards Heath, West Sussex, RH16 1UA
Tel: 00441444672264/ 07405909121
Email: info@wegoodcare.co.uk
Alternatively, complete the form, scan and send to info@wegoodcare.co.uk or complete online and submit.

Personal Details

Title Surname First Name Nationality Current Address Postcode Country Home Tel No Mobile E-mail Address

Registered General Nurses Only

NMC Number Speciality Current area work Any Gaps in your work (please explain) Renewal Date Band Experience

Health Care Assistants

NVQ: Yes/No Level Area of Work / Interest

Professional References

Second referee

Organisation Position Address Postcode Contact Details/Tel. No Postcode Email Referee Name Department Country

Second referee

Organisation Position Address Postcode Contact Details/Tel. No Postcode Email Referee Name Department Country

Mandatory Training

Please give details of the following training Certificates

Health and Safety at work

Fire Safety

Infection Control

Safeguarding

Adult Basic Life Support

Manual Handling

Administration of Medications

Venepunture and Cannulations

COSHH/RIDDOR

Rehabilitation of Offenders Act 1974-Order 1975 (amended in 2013)

The position you are applying for is an ‘eligible position’ under the Rehabilitation of Offenders Act 197(Exceptions) Order 1975 and in certain circumstances, the Police Act 1997. Enhanced disclosures may also include other relevant police information where this is deemed relevant to the position. Protected convictions and cautions will not be disclosed in a DBS check. This position has been identified as a regulated activity under the Safeguarding of Vulnerable Groups Act (2006) (as amended by the protection of Freedom’s barred list(s), as applicable to the position.

Do you have any convictions, cautions, reprimands or final warning that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) in the United Kingdom or in any other country? Yes No

If yes, please provide details of the conviction, caution, reprimands or final warning: including approximate date, the offence and the authority and the country which dealt with the offence.

Medical details

Please let us know if you have any illness/impairment/disability which may affect your work. Please let us know if you are having or waiting for treatment or investigations. Please let us know if you thing you need any adjustments or assistance to help you do the job.

Payment Details

Please provide your bank details where you would like your payment to be sent.

Bank/Building Society Name and Address Account Number Sort Code Name as in Account NI number

Declaration

I can confirm that the information given to We Good Care Ltd. Is correct and to the best of my knowledge and belief. If required I will be able to provide evidence to inform given in this document.

I will inform We Good Care Ltd. If my details given above or my circumstances changes.

Signature Name Date