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S34a West Midlands House, Gipsy Ln, Willenhall. West Midlands.
info@gracebrookcare.co.uk
01902275074, 07572164920.
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Online Application
Online Registration
Title
First Name
Surname
Preferred to be known as:
Address:
Post code:
Daytime Phone Number
Mobile Number
Email Address
Date of Birth
Do you hold a Current UK Driver's License?
Yes
No
Role:
Registered Mental Health Nurse(RMN)
Registered General Nurse (RGN)
Healthcare Assistant (Meds Comp)
Healthcare Assistant
NMC Number
NMC or HPC Expiry date
Membership other professional bodies
DBS Number
DBS Expiry date
Title
First Name
Surname
Daytime Phone Number
Mobile Number
Relationship
Postcode
Please tick the box that applies to you:
I am eligible to work in the UK and do not require a work permit
I am already in possession of a work permit to work in the UK
I need to obtain a work permit to work in the UK
Other (Please specify)
Does your DBS display any Cautions or Convictions?
Yes
No
Do you have any unspent criminal convictions?
Yes
No
If yes, please provide a statement, include any convictions and their dates.
Subject/Qualification
Place of study
Grade/Result
Year
Please provide the full name and work address of two professional clinical references that GRACEBROOK CARE LTD can contact. These should be your current / most recent employer and they must be able to comment on your ability to do the job you are applying for. Your referees must be a senior grade to yourself and you must have worked for the person for a period of more than three months.
Full Name
Establishment
Position
Address
Postcode
Telephone:
Email Address
Full Name
Establishment
Position
Address
Postcode
Telephone:
Email Address
Can we contact for references prior to the interview?
Yes
No
Have you applied to or worked for GraceBrook Care Ltd previously?
Yes
No
Please give details of your employment over the last 10 years. All gaps over 3 months must be accounted for. Include the month and the year, starting with your current or last job.
Date To:
Date From:
Employer’s Name
Job Title
Reason for Leaving
If you have a limited company, please ensure you attach the following information:
Proof of UK Limited Company Registration
Proof of Directorship of Ltd Company
Proof of RCN/RCM Membership
Signed Limited Company Contract
Confirmation that the Ltd Company is either VAT exempt or that you will absorb the VAT % when supplying to clients that are VAT exempt
Proof of UK VAT Registrationif relevant (Certificate - paper copy)
Limited Company Bank statement or letter of confirmation from your bank showing your bank details
Please tick here if you would like more information on working with umbrella companies for tax efficient savings
Personal/Financial Details Form - PLEASE, FILL IN BLOCK CAPITALS
TITLE
FIRST NAME
SURNAME
ADDRESS
POSTCODE
DATE OF BIRTH
NATIONAL IDENTITY(NI) NUMBER
(Please note, if you wish to be paid via a LTD Company, GraceBrook Care Ltd can only accept LTD Company Bank Account information)
Bank/Building Society Name
Bank/Building Society Address
Postcode
Account Holder’s Name
Sort code (always 6 digits)
Account Number
Confirm the above information is correct:
I confirm the above information is correct:
Send