MSM Healthcare Application Form

Step 1 of 10 – Personal Details

Please note that all fields must be completed. If a field is not relevant fill it in with ‘NA’.
Work Experience and Education
Please give details of your complete employment history, including reasons for any gaps, starting with present position. We require at least 10 years of unbroken work history. Click the + at the end of the row to add further rows.*
Please give details of your complete employment history, including reasons for any gaps, starting with present position.
We require at least 10 years of unbroken work history.
Click the + at the end of the row to add further rows.
Name & Address of Employer Position Date from Date to Grade Reason for leaving
Other*
Education/Training
Name of Establishment*
Address*
Date of Attendance: From*
To*
Qualifications and Grades*
Click the + at the end of the row to add further rows.
Additional/Professional Qualifications*
Rehabilitation of Offenders Act 1974 and Criminal Records
By virtue of the Rehabilitation of Offenders Act 1974 (Exemption) (Amendments) order 1986, the provisions of section 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 to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties. You should therefore list all offences even if you believe them to be “spent” or “out of date” for any reason.
Have you ever been convicted of a criminal offence?*
- Yes
- No
Have you ever been cautioned or issued with a formal warning for any criminal offence?*
- Yes
- No
If you have answered "yes" to either of the above questions, please give further details here. Alternatively, if you feel there is information of which we should be made aware or should be considered with regard to your application, please include that here.
If you have answered “yes” to either of the above questions, please give further details here. Alternatively, if you feel there is information of which we should be made aware or should be considered with regard to your application, please include that here.
The Disclosure & Barring Service is the executive agency of the Home Office responsible for conducting checks on criminal records. We are a registered body for the receipt of DBS disclosure information. Hospitals & Nursing Homes insist Agencies make informed recruitment decisions, that criminal record checks be made on all staff and you must apply for DBS disclosure. This disclosure will be compared with the information given above and any inconsistencies could affect your registration with us.
Signature*
Sign in the box below, using your mouse or touchpad if you aren’t using a touchscreen device. If you want to start again you can click on the symbol below the bottom right corner of the signature box to clear your signature.
Dated*
DD slash MM slash YYYY

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Please note that all fields must be completed. If a field is not relevant fill it in with ‘NA’.
Employee Consent Form

Retention of Disclosure & Barring Certificate
Employee’s Declaration of Consent
As an Employee of MSM Healthcare Ltd, I have applied for a DBS certificate as part of my screening. This is in line with current legislation regarding the screening of persons undertaking work in certain regulated activities and/or roles.

I understand that the DBS certificate when issued is my own property and as such, I have control over the decision to provide a copy to my employer to verify my eligibility to work within a specific role or sector.

I understand that MSM Healthcare Ltd has a statutory duty to carry out the relevant screening to verify whether any employee is either banned from working with Children and/or vulnerable adults or having a loving history which may affect eligibility to work in certain roles. Because of that statutory duty, I understand that if I, as an employee of MSM Healthcare Ltd, refuse to provide proof of eligibility to work within a certain role or sector, it will result in the withdrawal of my application.

Taking the above into account as well as my rights under the Data Protection Act 1998 and the Rehabilitation of Offenders Act 1974, I hereby provide my full and open consent for MSM Healthcare Ltd to retain a photocopy of my DBS certificate, filed separately from my personal file, for the duration of my employment.

I understand that this consent will be for the duration of my employment only and the consent will terminate if my service/employment with the Company is terminated by either party.

I understand that MSM Healthcare Ltd will only retain a hard copy of the certificate and will not transmit or supply my records, including my DBS Certificate, to any third party or associated company/partner without my prior consent. MSM Healthcare Ltd will securely destroy any copy of my dBS certificate upon termination of my employment.
Signed by Employee*
Date*
DD slash MM slash YYYY

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Application Form

Step 1 of 10 – Personal Details

Personal Details

Work Experience and Education

Education/Training

Rehabilitation of Offenders Act 1974 and Criminal Records

References

Reference 1

Reference 2

Reference 3 (Character Reference)

Health Declaration Form

Personal Information

Medical History

Tuberculosis

Immunisations

Exposure Prone Procedures – Immunisations

Declaration

Equal Opportunities Policy Monitoring Form

Carer Questionnaire

Employee Consent Form

Retention of Disclosure & Barring Certificate

Confidentiality Declaration

Payroll New Starter Form

Employee's Personal Details

Employee Statement

Student Loan

Student Loans Plans

Bank Details

Passport and Work Permits

Working Time Regulations Opt Out

Next of Kin (to be notified in case of emergency)

Document Upload

Name & Address of Employer	Position	Date from	Date to	Grade	Reason for leaving