Please complete our online application form below: Title SelectMrMrsMsMissDr First name Surname Email address Mobile telephone number Home telephone number Address Town/City Country Post code How did you find out about Regal Staffing? I am a SelectRegistered General NurseCommunity NurseDistrict NurseMental Health NursePrison NurseTheatre PractitionerRecovery NurseODPEndoscopy NurseDialysis NurseSpecialist Nurse (A&E, ITU, HDU)MidwifeHealth VisitorPaediatric NurseHCA (General)HCA (Mental Health)HCA (Learning Difficulties)HCA (Theatres)Other Date of birth Nationality Do you have right to work in the UK? (We will require documentary proof) SelectYesNo Are you a SelectBritish Citizen?EU Citizen?Indefinite Leave to Remain in the UK/Permanent Residence?International Student?Other? National insurance number NMC Pin Number (For Nurses) Position applied for Next of kin Next of kin contact number Current job title Current employer (please provide full address and dates of employment) Previous employers (please provide full address and dates of employment for the last 10 years including periods of unemployment) Reason for leaving Upload your CV (providing your CV will help us to find you the most appropriate positions) Uploading...: Cancel Please select the specialty or specialties that you would wish to be considered for. You must have gained clinical experience in these areas in the last 2 years Select A&E Anaesthetics Ante Natal Birth Cannulation Cardiac CCU CDU Chemotherapy Community Dermatology Dialysis District EMI Endoscopy Elderly General Wards Gynaecology Haemotolgy Health Visitor HDU Histopathology ITU Medical Mental Health Microbiology NICU Nuclear Medicine Nursing Home Nurse Practitioner Nurse Prescriber ODP Oncology Orthopaedics Paediatrics PICU Practice Nursing Prison Nursing Post Natal Radiology Recovery Renal Research and Development Residential Home SCBU School Nursing Scrub Substance Misuse Surgery Surgical Venepuncture Ventilation for Paeds Trachy Theatre X-ray Additional experience Educational qualification Date achieved Additional qualifications and training (please include dates attained) Are you up to date with your mandatory training (Basic life support, moving and handling, infection control etc)? (We will require proof of training) SelectYesNo Do you have an immunisation report or fitness to work certificate? (We will require proof) SelectYesNo Do you have a full UK licence? SelectYesNo Do you have access to a car? SelectYesNo Do you have any convictions? SelectYesNo If yes selected above, please provide details of any convictions Do you have indemnity insurance (e.g., RCN, Unison) SelectYesNo Please provide details of indemnity insurance (if you chose Yes above) Please provide details of 2 professional referees (Please include title, full name, physical address, email address and phone number) including a line manager or senior you have worked with in the last 12 months Additional Notes Bank Sort Code Bank Account Number Bank Name Equal opportunities (this information is collected for monitoring purposes only) Select your ethnic groupWhite BritishWhite IrishWhite otherMixed White and Black CaribbeanMixed White and Black AfricanMixed White and AsianMixed otherAsian or Asia BritishIndianPakistaniBangladeshiAsian otherBlack BritishBlack CaribbeanBlack AfricanBlack otherChinese Do you have a disability as described by the Disability Act (1995), i.e., do you consider yourself to be someone who has a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day to day activities SelectYesNo I certify that all information provided in this application form and supporting documents are true and complete to the best of my knowledge. I accept the Terms and Conditions. If this application leads to work placement, I understand that false or misleading information in my application, supporting documents or interview may result in withdrawal of any work offers. The personal information collected on this form and throughout the application process is solely for the purposes of recruitment, personnel administration and monitoring. In the instance that you (the applicant) are unsuccessful, the application form and supporting documents will be destroyed after six months. For all successful applicants the data will be used for administration of their employment with Regal Staffing in accordance with the Data Protection Act (1998), and for no other purpose. Regal Staffing’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background. Registration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about your clients. On no account must identifiable information relating patients or clients be divulged to anyone other than the Regal Staffing manager. Failure to observe these rules will be regarded as serious misconduct, which could result in removal from our register. The Working Times regulations 1998 (“The Regulations”) require Regal Staffing to limit your average weekly working time to 48 hours unless you agree that the limit shall not apply to you. To opt out of these regulations (which will apply until terminated by notice) on the basis that: 1. The 48-hour limit on average weekly time will not apply to you. 2. You may terminate the agreement (so that the 48 hour time limit would apply to you) by giving Regal Staffing 4 weeks written notice. Under the Regulations, Regal Staffing must keep records relating to your working time. This is the case whether or not you reach an agreement with Regal Staffing about waiving working time limits. Medical Records (Immunisation History) I do hereby give permission for Regal Staffing to have access to my medical records pertinent to my immunisation history. Rehabilitation of Offenders Act (Barring and Disclosure Service) - The DBS has issued a Code of Practice regarding Disclosure Information, a copy of which is available on their website and upon request. A Disclosure Certificate (enhanced) will be requested from the DBS, which will detail all convictions, including those which would otherwise be “spent”, as well as details of cautions, reprimands or warnings. The Disclosure Certificate will only be requested in the event that you are successful in your application for employment (if you do not already have one). Asylum and Immigration Act 1996 (Right to Work in the UK) Under Section 8 of the Asylum and Immigration Act 1996, it is a criminal offence to employ a person aged 16 or over who is subject to immigration control unless: • That person has current and valid permission to be in the United Kingdom and that permission does not prevent him or her from taking the job in question; or • The person comes into a category specified by the Home Secretary where such employment is allowed. Any employment offered will be subject to the successful applicant producing appropriate evidence that the Asylum and Immigration Act is not being contravened. Personal Declaration - I declare that to the best of my knowledge the above information, and that submitted in any accompanying documents, is correct, and: • I give permission for any enquiries that need to be made to confirm such matters as qualifications, training and references for the release by other people or organisations of such information as may be necessary for that purpose. • I give permission to allow processing of the personal data contained in this form for employment purposes • I agree that if I have given any false or misleading information, or do not give relevant information now or in the future, this may result in termination of an assignment without notice. • I acknowledge that I have been given a copy of the Terms and Conditions and access to the Nurse Induction Handbook by Regal Staffing and I will abide by those Terms and Conditions. Furthermore I hereby consent to Regal Staffing disclosing to the Authority/Client, or any person, firm or organisation duly authorised on the Authority/Client’s behalf, documentation for the purposes of an external audit required in accordance with the relevant authority. If you accept Regal Staffing’s proposals, please sign below (by checking the box provided). This document will then be the record of agreement. I have read and I understand the above and I agree to abide by the contents therein. Date SEND Thank you. We will be in touch shortly.