EmailMe Form - Greenstaff Medical UK

What is your title? *

If other, please confirm here:

What is your full name? *

First Last

What is your preferred name? *

First Last

What is your gender? *

What is your date of birth? *

DD / MM / YYYY

What is the best number to reach you on? (Mobile is usually best) *

Please confirm your number

What is your email address? *

Please confirm your email address:

What is your home address? *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Next of Kin

Please ensure your next of kin is based in the UK as well.

What is their name? *

First Last

What is their relationship to you?

What is their email? *

Please confirm their email

What is the best number for them? *

Please confirm their number

What is their address? *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Employment Details

Please ensure you answer all of the below questions:

Which of these are you currently working as? *

What is your professional Registration? *

Confirmation of Work Experience

Please confirm which areas you have worked in the past 12 months (please tick all that apply): *

What is your NMC/HCPC Pin Number (please put N/A if not applicable):

What is your Union Name (please put N/A if not applicable):

What is your Union Membership Number? (please put N/A if not applicable)

What is your Expiry Date of Union Membership? (please leave blank if not applicable)

DD / MM / YYYY

Education / Qualification Details:

Please ensure you answer all of the below questions:

Please provide details of relevant professional qualifications - please put N/A in any of the boxes that are not required:

	Qualification/Certification	Place of Study	Grade/Result	Year Completed
Most recent study
Previous study 1
Previous study 2

Criminal Records Check

The role(s) you are applying for will require a Disclosure and Barring Service (DBS) enhanced check or Protective Vulnerable Groups (PVG) Scotland check prior to and annually thereafter, for work in Regulated Activity with vulnerable adults and/ children.

Rehabilitation of Offenders Act and Unspent Criminal Convictions: The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) Exceptions Order 1975 (2013), (2016 Scotland) provide that certain spent convictions and cautions are ‘protected’ and are not subject to disclosure to employers and cannot be taken into account. Guidance and criteria on the protective filtering of cautions and convictions can be found by contacting the disclosure service

DBS Update Service:
If you are currently subscribed to the DBS Update Service, do you give us permission to check the certificate? *

Yes

No

Positive Disclosures Confirmation

If you have answered yes to the section as above, then please complete the following; I understand Greenstaff Medical will require further information to assess my application and suitability for roles with clients. If my application is progressed I hereby give Greenstaff Medical permission, to share the content of my DBS/ PVG/Access NI certificate with clients/organisations for the purpose of securing temporary work for me. *

I agree

Declaring Positive Disclosures / Criminal Activity

Failure to declare information that is later found to be held on your DBS, PVG or Access NI, may require us to exclude you from our register, discontinue your application, or terminate an assignment if an offence is not declared but later comes to light. Any information given will only be considered in relation to your application for regulated activity positions with our clients and will be managed in accordance with the DBS Code of Practise and Disclosure Scotland code of Practise for PVG. If applying to work in England and/or Wales (DBS): Do you have 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) *

Yes

No

Appraisal Details:

Please provide details of your most recent appraisal:

What was the date of your most recent appraisal? (please leave blank if not applicable)

DD / MM / YYYY

What is the name of your apprasier? (please leave blank if not applicable)

First Last

Employment History

Please ensure you complete as much information as you can on the below:

Employer 1 (current / most recent employer) *


Employer Name
Start Date (Month and Year)
End Date (Month and Year)
Job Title
Roles/Responsibilities
Reason for Leaving

Employer 2 (please leave empty if not applicable)


Employer Name
Start Date (Month and Year)
End Date (Month and Year)
Job Title
Roles/Responsibilities
Reason for Leaving

Employer 3 (please leave empty if not applicable)


Employer Name
Start Date (Month and Year)
End Date (Month and Year)
Job Title
Roles/Responsibilities
Reason for Leaving

Employer 4 (please leave empty if not applicable)


Employer Name
Start Date (Month and Year)
End Date (Month and Year)
Job Title
Roles/Responsibilities
Reason for Leaving

References

Please provide details of your current / recent employers to contact for a professional reference, regarding your work in the UK in the past 2 years. References from outside the country will not be accepted and references must be clinical/care related.

Kindly also note that all references need to be verified and all nurses completing references need to provide NMC pin numbers on the reference form.

Reference 1 *


Full Name:
Organisation Name:
Referee's Position
Email Address:
Phone Number:
Address:
Post Code

Reference 2 *


Full Name:
Organisation Name:
Referee's Position
Email Address:
Phone Number:
Address:
Post Code

Investigations, Terminations & Fitness to Practice:

If you are applying for a post that requires professional registration you are required to provide the following information:

Have you ever been suspended or terminated from a Health or Social Care role? *

Yes

No

Are you currently the subject of a fitness to practise investigation or proceedings by a licensing, regulatory body or other organisation in Ireland or in any other country? *

Yes

No

Have you been removed from the register or have any conditions been made on your registration by a fitness to practice committee or the licensing or regulatory body in Ireland, or in any other country? *

Yes

No

If you have answered yes to any of the above questions, then please provide further details: *

Working Time Regulations 1998:

The European Union has laid down guidelines for all workers, governing the length of the maximum working week that is safe to work. The current limit is 48 hours per week. You are under no obligation to accept any work offered, and you will not be compelled to work more than 48 hours per week, however you may choose to do so. A full explanation of the Working Times Regulations 1998 can be found in your Staff Handbook.

Please select as appropriate: *

I do NOT wish to work more than 48 hours per week. Due to the nature of temporary work I understand that Greenstaff Medical cannot monitor work patterns outside of Greenstaff Medical’s control and therefore it is my responsibility to monitor this.

I DO wish to work more than 48 hours per week.

Data Protection:

Legal Compliance: I understand that Greenstaff Medical retains the right to hold this application and any other data, including data that is considered ‘personal’ and/ ‘special’ that is required to process for the purpose of complying with their legal obligations of my recruitment and supply to suitable assignments with contracted clients, and to retain these details for as long as reasonably necessary in accordance with the General Data Protection Regulation (GDPR)(Regulation (EU) 2016/679) and our contractual obligations.

I consent to Greenstaff Medical processing data outside of the European Economic Area (EEA) in their secure processing centres in India and South Africa. *

Yes

No

Please Note: If consent is not given for processing your data outside the EEA, we will be unable to progress your application and will destroy all records held

Marketing Contact Permissions:

As part of our service, we would also like to offer you relevant professional information, including:

- Useful news and features about your profession
- Events, competitions and promotions we are running
- Surveys and opportunities for you to offer your views and insights
- Ongoing career opportunities during breaks of 12 months or more from temporary work assignments with us.

We may use your email, postal address, mobile number and/or job title information to send you the most relevant career opportunities. Please let us know how you prefer to be contacted for marketing purposes. please select as applicable: *

Email

Telephone

SMS/Instant Messaging

Holiday Pay:

Whilst working for the agency, the temporary worker will accumulate Holiday Pay calculated as a percentage of the hourly rate of pay.

We co-ordinate leave from April to April. All requests must be made within the correct time period.

Should you submit a request later than 31st March you will no longer be entitled to holiday pay for the previous year.

If applying for holidays, the temporary worker must give a minimum of 1 weeks notice to the Registered Manager or Sales Manager at the agency.

I have read, understand and will comply with the Working Holiday Entitlement Clause.

For the purposes of your employment with us, the holiday year will be the 12 month period commencing on the 6th April (and, if applicable, each subsequent 12 month period).

All entitlement to leave must be taken during the course of the holiday year in which it accrues and none may be carried over into the next holiday year.

The agency is not required by law to make any payment in lieu of unused holiday at the end of the holiday year.

When making your holiday plans please observe the following:

You should not normally plan to take more than two weeks at any one time although a longer period may be granted in special circumstances.

Notice must be given of either 1 week or equivalent to the total length of the holiday, whichever is the greater. *

I agree

Payment Details

Please confirm your preferred method of payment:

Umbrella Company

Danbro Accounting LTD

JSA Services LTD

Giant Professional

Other* - Please provide Umbrella Company Name

*Subject to approval by Greenstaff Medical prior to payment method being approved.

Umbrella companies are required to comply with IR35 guidelines. Please check with your consultant if you Umbrella company meets these requirements.

Please confirm that you

Agree to the terms and conditions of the above selected Umbrella company.

Understand that registration with my chosen Umbrella company is my responsibility and that a delay in registration may delay payment.

Consent to ICG sharing your personal details with your chosen Umbrella company for payment for work completed.

PAYE

Please provide your bank details

Payee Name (as it appears on your account): *

First Last

Account Number: *

Sort Code: *

Terms & Conditions

Our Terms & Conditions for working with us can be viewed online by copying and pasting this link into your brower: https://bit.ly/3tpUpXb

You can also view our Agency Worker handbook Declaration for Acute and Nursing Homes here: https://shorturl.at/9V6M0

You can also view our Agency Worker handbook Declaration for Community Services here: https://bit.ly/3XNZEOq

Please confirm you have read and understood these T&C *

I confirm

Please sign below to confirm the details in this form are correct and true: *

Clear

Please confirm the date: *

DD / MM / YYYY