Please give the names and contact details of 2 professional references from your current and most recent employment/education. Referees must have worked in a senior position to yourself. Please be aware that G & H Personnel are unable to offer you work until satisfactory references have been obtained.

Applicants for Healthcare positions are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare your prosecutions or convictions, including those that are ‘spent’ under this Act. Please tick.

G & H Personnel will undertake an Enhanced DBS check on your behalf. You will not be placed without having a current DBS check. This process will be explained, and will be completed if your application is successful.

The Working Time Regulations 1998 require G & H Personnel to limit your average weekly working time to 48 hours unless you agree with G & H Personnel that the limit shall not apply to you:

I can confirm that I have read this document fully and that all the information provided to G & H Personnel is correct and to the best of my knowledge and belief. I give consent to contact referees regarding the information I have provided unless specified otherwise. I will inform Your G & H Personnel should anything change that might affect my position and I understand the information given on this form will be processed by computer and used for registration purposes, under the Data Protection Act 1998.

1. I understand that if I am at any stage charged or cautioned after signing this declaration, I must inform G & H Personnel.

2. I acknowledge that I have been given a copy of the terms and conditions of service issued by G & H Personnel which is mine to keep, and furthermore that I have read those terms and conditions and agree to abide by them.

3. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my Occupational Health Form.

4. I acknowledge and confirm that G & H Personnel is authorised to apply for and obtain a Disclosure and Barring Service (DBS) check and references from any previous employers and educational establishments.

5. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future that G & H Personnel may cease to offer me further agency placements without notice, as well as claim for recovery of any payments I have received, together with a claim for loss of profit to G & H Personnel.

6. I agree that the maximum weekly working time specified in Regulation 4(1) and (2) of the Working Time Regulations 1998 shall not apply to working with G & H Personnel unless specified above.

7. I acknowledge that my personal details will be stored and handled correctly by G & H Personnel in accordance with the Data Protection Act 1998, however, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents - DBS, Occupational Health, References).

8. I understand that if I am on a student visa I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student changes, I must inform G & H Personnel.

9. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform G & H Personnel.

10. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for G & H Personnel, I must inform G & H Personnel immediately.

11. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will inform G & H Personnel if I am under investigation or suspended by my professional regulatory body or employer at any point while working for G & H Personnel.

12. I confirm that when asked about my working history (primarily, but not exclusively, for the purpose of the Agency Workers Regulations) I will provide accurate information.

13. I acknowledge that should I reach the 12 week Qualifying Period under the Agency Workers Regulations, I may be asked for, and will provide, further documentation as evidence of qualifying weeks, if G & H Personnel deem it necessary.