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Title (Mr, Mrs etc.)

Mr
Mrs
Miss
Ms

Sex *

Male
Female

Contact Name *

First

Last

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

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Mobile Telephone: *

Age *

National Insurance No: *

Contact Email *

Home Telephone:

Date Of Birth: *

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What is the earliest date you could start work with us?

Do you hold a current UK driving licence?

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We require your work history including periods you may have spent out of employment. Therefore, please list your full employment history here, including any periods when you were not working with a brief explanation of what you were doing. You may use the "additional info" box below.

Please start with your current or most recent employment and work backwards. We require 5 years of work history.

Employment 1

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Place of employment

Position:

Period of Employment: From: To:

Brief Description of Duties:

Reason for leaving:

Employment 2

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Place of employment:

Position:

Period of Employment: From: To:

Brief Description of Duties:

Reason for leaving:

Employment 3

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Place of employment:

Position:

Period of Employment: From: To:

Brief Description of Duties:

Reason for leaving:

Employment 4

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Place of employment:

Position:

Period of Employment: From: To:

Brief Description of Duties:

Reason for leaving:

Employment 5

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Place of employment:

Position:

Period of Employment: From: To:

Brief Description of Duties:

Reason for leaving:

Additional info:

We take our responsibility to protect our clients very seriously at NuHealth Care Services LTD. Your appointment depends on the successful completion of a criminal records disclosure. At this point, we require you to answer the following questions truthfully and honestly:

Have you received any convictions, cautions, reprimands or final warnings that are not ‘protected’ as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013 by SI 210 1198)? *

To your knowledge, are you currently the subject of any criminal proceedings (for example, charged or summoned but not yet dealt with) or under any police investigation? *

If you answered ‘yes’ to either of the two previous questions, please provide details:

Do you consent to NuHealth Care Services LTD applying for an enhanced criminal records disclosure on you and keeping a copy of your disclosure certificate for the duration of your employment or until a new disclosure is completed *

It should be noted that if it is discovered after a criminal records disclosure that you have failed to accurately disclose the information requested above, the company reserves the right to terminate your employment without notice. Please be aware, however, that having a criminal record does not automatically preclude us from hiring you; if you would like to learn more about our policy on the recruitment of ex-offenders, please enquire.

We accept references for a minimum of three years. One reference should be from your current employer. College or University graduates should identify their lecturers/tutors/professors. Please keep in mind that friends and family do not qualify as suitable referees.

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Current Employer

Title and Name of Reference

Address and postcode of referee: *

Address Line 1

City

State / Province / Region

Contact Number *

Email address: *

Capacity Known to you: *

Do you give us permission to contact your referee? *

2 nd Reference

Title and Name of Reference

Address and postcode of referee: *

Address Line 1

City

State / Province / Region

Contact Number *

Email address: *

Capacity Known to you: *

Do you give us permission to contact your referee? *

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Curriculum Vitae