HealthCare – Intrepid Global

"*" indicates required fields

APPLICATION FORM

1 OF 2

Personal Details:

First Name*

Surname*

DATE OF BIRTH*

HOME TEL*

WORK TEL*

MOBILE*

Email Address*

Address*

Street Address City

NATIONAL INSURANCE*

Next Of Kin (In case of Emergencies):

Full Name*

RELATIONSHIP*

TEL NO 1*

TEL NO 2*

REFERENCE 1

Name*

TEL NO*

Email*

ORGANISATION*

POSITION*

EMPLOMENT DATE FROM*

EMPLOMENT DATE TO*

REFERENCE 2

Name*

TEL NO*

Email*

ORGANISATION*

POSITION*

EMPLOMENT DATE FROM*

EMPLOMENT DATE TO*

COVID STATUS: *

(PLEASE TICK) :

COVID STATUS*

NOT VACCINATED

ONE VACCINATION

DOUBLE VACCINATION

BOOSTED

ELIGIBILITY OF EMPLOYMENT:

NATIONALITY*

IMMIGRATION STATUS:

VISA*

EU PASSPORT

RIGHT TO ADOBE

TIER 1

ANCESTRY VISA

TIER 2

SPOUSAL VISA

TIER 3

Consent*

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 Intrepid Global. Pick tick to acknowledge:*

Declaration of Criminal Records:

Do you have any unspent criminal convictions, cautions, reprimands or warnings?*

YES

Are you subject to any pending proceedings?*

YES

criminal convictions

If yes, please list your criminal convictions and their dates below. The information you give will be treated in confidence and only taken into account where, in the reasonable opinion of the Company the offense is relevant to the post for which you are applying. Certain types of employment and certain professions are exempt from the Rehabilitation of Offenders Act 1974 and in those cases particularly where the employment is sought in relation to positions involving working with children or vulnerable adults details of all criminal convictions, both spent and unspent , must be given. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment if the offense is not declared but later comes to light.

Professional Conduct:

Are you currently subject to or have previously been subject to any suspension, investigation, serious complaint or dismissal by an employer, professional body or regulator?*

YES

Professional Conduct

If yes, please give details:

Working Hours:

The working time regulations stipulates that employers will limit your average weekly working time to 48 hours, should you wish to waive this right, please confirm here:*

YES

TERMS:

TERMS

I declare that the information given, as well as any documentation provided is accurate. I agree that if I have given false information or have refused to submit any relevant information, this may lead to the application being declined or instant dismissal from an or any assignment.

I declare that I have received and read Intrepid Globals candidate handbook and accept the applicable terms of engagement which I understand are available from the company.

I acknowledge that my personal details will be stored and handled correctly by Intrepid Global in accordance with the General Data Protection Regulations (2018). I agree that my personal details, including all documentation, may be made available for audit by customers and clients of Intrepid Global and their appointed auditors.

I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or previous employer. If at any time during my application or employment with Intrepid Global I am investigated or suspended by another employer or my professional regulatory body I will inform Intrepid Global immediately.

AGREE

DECLARATION:

I declare that I have received and read Intrepid Globals candidate handbook and accept the applicable terms of engagement which I understand are available from the company.

I authorise Intrepid Global to disclose any convictions either declared, stated on a DBS Disclosure or other police check to any potential employers in accordance with our internal policy, the DBS Code of Practice and the Rehabilitation of Offenders Act. If at any time during my application or employment with Intrepid Global I am investigated by the Police, cautioned or convicted of any offence I will inform Intrepid Global immediately.

I conform that when asked about my working history, (primarily, but not exclusively, for the purposes of the Agency Workers Regulations) I will provide accurate information. 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 Intrepid Global deem it necessary.

Additional Information:*

FULL NAME*

SIGNATURE*

DATE*

PLEASE SELECT*

Compliance:

Upload Your Documents, supported file (Max 15MB)

Upload CV

Drop files here or

Max. file size: 256 MB.

Upload Passport Photo

Drop files here or

Max. file size: 256 MB.

upload DBS Certificate

Drop files here or

Max. file size: 256 MB.

upload Proof of N.I

Drop files here or

Max. file size: 256 MB.

upload Full Immunisation record

Drop files here or

Max. file size: 256 MB.

upload NMC Statement of Entry

Drop files here or

Max. file size: 256 MB.

upload Proof of Indemnity Insurance

Drop files here or

Max. file size: 256 MB.

upload Certificate of Qualifications

Drop files here or

Max. file size: 256 MB.

upload Mandatory Training Certificate

Drop files here or

Max. file size: 256 MB.

upload 2 x Proof of Address

Drop files here or

Max. file size: 256 MB.

PAYE FINANCIAL FORM

2 OF 2

EMPLOYEE BANK DETAILS:

ACCOUNT NAME*

SORT CODE*

Account Number*

BANK NAME*

BANK ADDRESS*

I confirm the details I have provided regarding my bank details are correct

SIGNATURE*

PRINT NAME*

DATE*

LTD FINANCIAL FORM

2 OF 2

LIMITED COMPANY BANK DETAILS:

Please complete all details clearly in black ink and block capitals and return to us as soon as possible.

ACCOUNT NAME*

SORT CODE*

Account Number*

BANK/BUILDING SOCIETY NAME*

Please note that Intrepid Global is unable to pay any monies until we are in receipt of all documents as detailed below and followed by a signed contract which will be issued upon receipt of these documents.

LTD DOCUMENTS

Certificate of incorporation

VAT certificate (if applicable)

I confirm the details I have provided regarding my bank details are correct

SIGNATURE*

PRINT NAME*

DATE*