Apply - Mac Care

POSITION APPLIED FOR: *

PERSONAL DETAILS

Full Name (Mr/Mrs/Ms): *

Address: *

Postcode: *

Home Telephone No: *

Work Telephone No: *

Mobile Telephone: *

Email Address: *

Nationality: *

Religion: *

Type of Transport: *

Do You Hold a UK Driving Licence: *

National Insurance Number: *

Pin
(Qualified Nurse Applicants only):

Pin expiry Date:

Name of Emergency Contact: *

Relationship to you: *

EMPLOYMENT DETAILS

Currently Employed: *

Yes

Company:

Position:

Period Employed From:

Period Employed To:

Reason For Leaving:

Company:

Position:

Period Employed From:

Period Employed To:

Reason For Leaving:

Company:

Position:

Period Employed From:

Period Employed To:

Reason For Leaving:

EDUCATION AND TRAINING

Name and address of school/college/Nurse Training School/Other:

Course or subjects taken and (any) qualifications gained:

From Mth/Yr:

To Mth/Yr:

Name and address of school/college/Nurse Training School/Other:

Course or subjects taken and (any) qualifications gained:

From Mth/Yr:

To Mth/Yr:

Name and address of school/college/Nurse Training School/Other:

Course or subjects taken and (any) qualifications gained:

From Mth/Yr:

To Mth/Yr:

LANGUAGES

Please list the languages in which you are fluent (including your Mother tongue)

Languages:

WHICH OF THE FOLLOWING HAVE YOU WORKED IN BEFORE

SHIFTS PREFERRED

Part Time

Full Time

Nights

Areas That Can Be Covered: *

Date available to start: *

REHABILITATION OF OFFENDERS ACT 1974

By virtue of the Rehabilitation Act 1974 (Exceptions) (Ammendments) Order 1986, the provisions of sections 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such a kind as to enable the holder to have access to persons in receipt of such services in the course of his/her noraml duties. Your answer to the following question should include any 'spent' convictions.

Have you ever been convicted of a criminal offence: *

Yes

If 'yes' please give details:

DOH circular (88/9) Protection of Children requires us to carry out checks on police records for members whose assignments will give them substantial access to children. Do you agree that such checks may be made concerning you if validate ?: *

Yes

Do you have a current CRB?:

Yes

REFERENCES

Please provide details of 2 referees who can provide information relating to your competence in a caring role (one of whom should be your present or mst recent employer). Relatives and friends are not acceptable.

Address: *

Postcode: *

Position: *

Organisation: *

Telephone: *

May we approach the above prior to interview ?: *

Yes

Name: *

Address: *

Postcode: *

Position: *

Organisation: *

Telephone: *

May we approach the above prior to interview ?: *

Yes

HEALTH QUESTIONAIRRE

All information is held in confidence.

Back related problems: *

Yes

Nervous Breakdown/mental disorder: *

Yes

Diabetes: *

Yes

Migraine: *

Yes

Dysmenorrhoea: *

Yes

Epilepsy: *

Yes

Eczema: *

Yes

Heart or circulatory illness: *

Yes

Blood disorders or anaemia: *

Yes

Recurrent attacks of diarrhoea: *

Yes

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

2. Have you ever had any major accidents or head injuries: *

Yes

If yes, please give details:

3. Have you ever had any major operations or illnesses?: *

Yes

If yes, please give details:

4. Do you have or are you a carrier of any communicable diseases?: *

Yes

If yes, please give details:

Rubella (German Measles): *

Yes

Tuberculosis: *

Yes

Tetanus: *

Yes

Hepatitus B: *

Yes

Polio: *

Yes

6. Do you have any allergies (e.g. penicillin) ?: *

Yes

If yes, please give details:

Height: *

Weight: *

Blood group: *

8. Are you currently receiving any medication or treatment ? : *

Yes

If yes, please give details:

Are you a smoker ?: *

Yes

Are you at this time pregnant ?: *

Yes

Have you ever been refused employment on health grounds ?: *

Yes

How many days off sick have you had in the last 12 mths ?: *

Name address and telephone number of next of kin: *

Personal Skills: *

BANK DETAILS

Wages are paid direct into account. Please give below details of the account you would like your wages paid into:

Name and Address of Bank or Building Society: *

Name of Account Holder: *

Type of Account (current,deposit etc): *

Account Number: *

Sort Code: *

Reference Number (if Building Society):

I hearby authorise you to remit all amounts due to me for the credit of the account detailed above.

DECLARATION

I confirm that I am 18 years of age, or over.

I full accept that I am applying for membership of MAC CARE, in the full comprehensive understanding that I should accept an introduction from MAC CARE the services that I provide are on a self employed basis. As a self employed person, I accept that MAC CARE duty is that of an agent, not employer and in signing this disclaimer I acknowledge that neither MAC CARE nor it's employees, hold any repsonsibility or liability whatsoever for the services that I provide, nor for the consquences of the provision of such services, including personal accident, damage to client's property etc.

I declare that all the information given is true and I understand that any false or misleading information may result in my removal from the MAC CARE Register of Members.

I have read and greed to abide by the conditions of membership.

I accept my duty to inform MAC CARE of any change in circumstances that may affect my emplyment status.

I can confirm that I am eligible to work in the UK.

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PERSONAL DETAILS

EMPLOYMENT DETAILS

EDUCATION AND TRAINING

LANGUAGES

WHICH OF THE FOLLOWING HAVE YOU WORKED IN BEFORE

SHIFTS PREFERRED

REHABILITATION OF OFFENDERS ACT 1974

REFERENCES

HEALTH QUESTIONAIRRE

BANK DETAILS

DECLARATION