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Employee Registration Form
NAME:
Employee No:
DOR:
Please complete this registration form in black ink or typed face and then return to the
AAA Recruitment Solutions Ltd (email address: [email protected])
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35 Manchester Road, Preston PR1 3YH
Web: www.aaahealthcare.co.uk E-mail: [email protected]
Telephone: 01772 386299 Mobile: +44 074 78995777 +44 07399579a282
AAA RECRUITMENT SOLUTIONS LTD
Registration Form
Thank you for registering with AAA Recruitment Solutions Ltd. To complete your registration please work
through this registration pack to the best of your ability. If you have any questions or queries, please do not
hesitate to use the contact details on the front page and we will help in any way we can.
We will also require the following documents prior to you starting work with AAA Recruitment Solutions
Ltd:
Completed registration pack Proof of right to work in the UK Proof of identity-if not same as above 2 proofs of Address/Bank letter Proof of your National Insurance Number Reference details for the last 5 years All relevant details, certificates and qualifications Vaccination certificate Enhanced DBS check/DBS details 2 passport photos A copy of your up to date CV P45/P46
Please note that it is a legal requirement to have a valid enhanced DBS (Criminal Record Check).
AAA Recruitment Solutions Ltd will not place you into employment without this check. We can and will conduct this on your behalf; however, there is a cost of £52.40 which will be required to be paid by yourself upon registration. However, if you have already carried out a DBS check with another organisation and are subscribed to DBS checking service you must provide a DBS registration number to us. For more information about DBS checking service, please visit https://gov.uk/disclosure-and-barring-service-criminal-record-checks-referrals-and-complaints
Please also provide us with a fitness to work certificate.
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Registration
Personal Details
Title (Mr, Mrs, Ms, Miss)
First Name(s)
Surname
Address
Postcode
Nationality
Contact number
Date of birth
National Insurance Number
What kind of work are you
looking for?
Please attach CV (if applicable) or Email to [email protected]
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Employment History
From - To Job Title Employer’s details Reasons for leaving
From – To
Job Title Employer’s details Reasons for leaving
From – To
Job Title Employer’s details Reasons for leaving
Education
Year University/College/School Qualifications
Please use an additional sheet if necessary.
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References
Name
Relation
Address
Telephone
Name
Relation
Address
Telephone
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Next of Kin
Name
Address
Postcode
Contact Number
Bank Details
Bank name
Bank address
Name of Account Holder
Sort code
Account Number
(N.B. If you feel uncomfortable giving us the data above at this point, we are happy to take it at any
point prior to commencement of work)
Health Information
(Please fill in the following form with your current GP’s details)
Doctor’s name
Practice name
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Address
Postcode
Telephone number
Please read carefully and answer every question to the best of your knowledge. If you answer YES, you
must provide further details. Failure to do so will result in a delay in processing your assessment.
Yes No
1) Have you ever had a health condition that may have been caused by work?
2) Do you have any health condition that you think may affect your performance
or safety at work?
3) Do you have any problems with hearing?
4) Do you have any problems with your eyesight (not corrected with
spectacles/contact lenses)?
5) Have you had any skin problems e.g. eczema, psoriasis, recurrent skin
infections, allergic rashes?
6) Have you ever experienced a fit, blackout or unconsciousness?
7) Have you ever had any mental health problems (e.g. anxiety, depression,
nervous breakdown, stress, self-harm, eating disorders and addictions)?
8) Have you ever been admitted to hospital?
9) Are you taking any medication (excluding contraception), or are you under any
form of treatment at the moment?
10) Do you have any health conditions that cause difficulty with;
Sitting
Standing
Moving around
Bending, lifting or carrying
Working with a computer
11) Are you waiting for any investigations, treatment or admission to hospital?
12) Have you consulted a doctor/GP/specialist in the last year?
13) Have you been absent from work/study due to illness in the last two years?
If YES give details of the number of occasions, the reason and the duration of
each absence below.
14) Do you have any disability or health condition not already mentioned for which
you think you may require support or adjustments to do your job?
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Patient safety code
For all staff involved in care of patients.
If you are HIV positive, or suspect that you maybe, and you will be involved in the care of patients,
you must declare this in confidence to staff at AAA Recruitment Solutions Ltd. If aspects of your work
may involve a risk of transmission to patients, you must not carry out such work until the risk has been
assessed any necessary measures to prevent transmission agreed and implemented.
During your employment you must inform the agency, if at any time:
You are diagnosed as HIV positive or suspect that you may have been infected with the virus.
you contract any other infection which could be transmitted to and endanger patients.
If your work involves you undertaking or assisting with surgical or exposure prone procedures, you
cannot be passed fit for work until we have obtained satisfactory documented evidence of your
hepatitis B status or other tests necessary to comply with our Control of Infection policies. You must
also inform us if you have ever been tested positive for any transmissible blood borne virus infection
such as Hepatitis B, Hepatitis C or HIV.
I have read the above and agree to comply with the agency’s Patient Safety Code
Signed………………………… Date……………………..
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Night Workers Declaration
This declaration is to excess if you have any health conditions that may affect your ability to person
night work.
This assessment is now a requirement of the Working Time Regulations Act 1988.
Do you have any health factors that may affect your fitness to do your night work?
Yes:
No:
If yes, please explain below.
DECLARATION:
I declare that the foregoing statements are true and complete to the best of my knowledge
Signed: ……………………………………… Date: ……………………………
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Criminal Conviction form If your application is successful and you take up employment with us, it is possible that you will be asked to
verify the information given here by obtaining a Criminal Records Bureau Disclosure.
Name:
Are you registered with any professional bodies: Yes: No:
If yes, please state:
Have you been subject to any kind of investigation/suspension by either an NHS body, or other wider public sector body, or
their relevant professional and regulatory body?
Yes: No:
If yes, please give further details:
Are you subject to any kind of investigation or prosecution
relating to a conviction, or which could lead to a conviction
since your most recent criminal record check was undertaken?
Yes: No:
If yes, please give further details:
Do you have any unspent/spent criminal convictions? Yes: No:
Offence Details Sentence Date of sentence
This information given by me in this form is to the best of my knowledge and belief, and it is true and
correct. I also understand that any misrepresentation by me will lead to the withdrawal of any offer of
employment, or my employment being terminated without any obligation of liability on the part of the
employer other than for services rendered.
I also confirm that if I become subject to an investigation by my professional body or a matter in
which could lead to a conviction, I will let the agency know straight away.
Signature:
Date:
*Certain types of employment and 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 for
all criminal convictions must be given. The information given will be treated in the strictest of confidence and only taken into
account where, in the reasonable opinion of AAA Recruitment Solutions Ltd, the offence is relevant to the post to which you are
applying. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment I the
offence is not declared but later comes to light.
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CRB Form In order to work for AAA Recruitment Solutions Ltd, you are required to carry out a CRB check with us.
The cost of this is £52.40.
Please provide the following information in order to complete your CRB check:
Previous addresses for the last 5 years: Dates from and to:
Previous Names: Dates from and to:
I give consent for AAA Recruitment Solutions Ltd to complete a CRB check along with my
application documents.
Signature:
Print Name:
Date:
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Confidentially Agreement
I ……………………………………………...confirm that during every assignment and afterwards I
understand the importance of:
Holding information relating to the client in the strictest confident, ensure it is kept safely and securely
when not in use. I acknowledge they no information is to be removed from the client’s premises
without the permission of the Client.
Using such information on for the purpose of the work for which it was given.
You must under no circumstances disclose any entry codes, security procedures, keep or make copies
of any keys fir any placement to any third parties without the express permission of the place of work,
and AAA Recruitment Solutions Ltd.
Under no circumstances must you use foul language, disruptive behaviour, use mobile phones during
contracted hours, or sleep during contracted work hours, even during breaks.
Please remember all candidates much act professional at all times, and respect the wishes of the staff
and clients.
Not disclosing to any third party or copy the information except as is required in the course of my
duties.
Any breach, either by me or third party, may result in legal proceedings being brought by the Client
against me to recover any losses that occurred as a result of a breach.
Signature:
Print Name:
Name:
Health Declaration
I can confirm that if I do become injured, diagnosed with any medical conditions or become pregnant I will
let the agency know straight away so they can undertake necessary provisions and ensure that I am not
exposed to any work conditions which could cause risk.
Signed:
Dated:
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Permission to work in the UK
Do you have immigration permission to work in the UK? Yes: No:
In line with UKBA guidance on the prevention of illegal working we will need to verify and take a copy of
your original ID documentation as evidence of your right to work in the UK if you are to be engaged by AAA
Recruitment Solutions Ltd for temporary work.
48 Hour Opt Our Agreement
I… agree that I may work for more than an average of 48hours a week. If I change my mind, I will give my
employer …………… (Months) notice in writing to end this agreement.
Signature:
Print Name:
Dated:
Audit Consent
If you are successful in your application, your documents may be required for auditing purposes.
I ………….. …………….confirm that I give permission for my file to be audited by a third party company.
Signature:
Print Name:
You are signing this form as confirmation that you have read and fully understood our Code of Conduct. By
signing this you are taking full responsibility for yourself in regards to any breach of this contract. If a breach
of contract has been made you will be subject to a disciplinary hearing so, please make sure you have fully
understood the document.
Signature:
Print Name:
Date:
Incomplete forms may be returned and may delay in offering you agency work.
ALL SUCCESSFUL CANDIDATES SHOULD COMPLETE THE DECLARATION BELOW.
Declaration I hereby confirm that the information given is true and correct. I have read and understood all
statements.
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If, during the course of a temporary assignment, the Client wishes to employ me direct, I
acknowledge that AAA Recruitment Solutions Ltd will be entitled either to charge the client an
introduction/transfer fee, or to agree an extension of the hiring period with the client (after which I
may be employed by the client without further charge being applicable to the client).
Signature:
Print Name:
Date:
AVAILABILITIES:
Please tick what days you are available,
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Signature:
Print Name:
Date:
35 Manchester Road, Preston PR1 3YH
Web: www.aaarecruitmentsolution.co.uk E-mail: [email protected]
Telephone: 01772 386299 Mobile: +44 074 78995777 +44 07949077669