Step 1 of 6 - Personal details 0% Personal detailsTitle*Please select a titleMrMrsMissMsDrOtherName* First Middle Last Known as Gender*Please select an optionMaleFemalePrefer not to sayDate of birth* Day Month Year House numberStreet Town / city* County* CountryPlease select your countryUnited KingdomAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwePostcode Home phoneMobile phoneEmail* GradePlease select your gradeBand 2Band 3Band 4Band 5Band 6Band 7N/ANI Number* Job title* Are you looking for full time work (minimum of 3 shifts per week)?* Yes No Emergency contactName* First Last Their phone number*Their relationship to you*Please select an optionParentChildSiblingAunt/UncleNiece/NephewCousinGrandparentOtherRight to workAre you legally eligible to work in the UK?* Yes No Are you required to have a UK work visa / permit?* Yes No Professional registration (if applicable)Issuing bodyPlease select an optionNMCSCWSocial Work EnglandN/APIN Have you ever been investigated, removed, or suspended by a professional body? Yes No As you answered YES to the previous question, please provide details. Rehabilitation of Offenders ActHave you ever been convicted, cautioned, reprimanded, or given a final warning for a criminal offence?* Yes No As you answered YES to the previous question, please provide details.Are you waiting to hear about any prosecutions pending?* Yes No As you answered YES to the previous question, please provide details.Have you ever been the subject of a disciplinary investigation or proceedings by a previous employer in any position you have held?* Yes No As you answered YES to the previous question, please provide details.Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability?* Yes No As you answered YES to the previous question, please provide details. ConsentI consent to 3rd party audit checks* Yes No I consent for Bluestones Medical to apply for a DBS, for DBS update service checks and retention of a copy of my DBS certificate* Yes No I consent for my personal data to be supplied to your preferred umbrella company (if applicable)* Yes No I consent to approach references* Yes No I consent to Right to Work checks* Yes No I consent to Professional Regulatory Body checks* Yes No I consent for Bluestones Medical to provide copies of my CV, DBS and references to any prospective employer for the purposes of securing work* Yes No I will only accept roles relevant to my skills and experience. I will express interest in roles where I believe my skills are transferable but understand that this decision will lie with the client as to whether I am eligible for appointment.* Yes No ReferencesPlease ONLY provide reference details of an individual who you reported into/directly managed you. Please note we are only able to accept professional email addresses. We are not able to accept any references from a personal email address. Please complete the reference details for every employment within last 3 years (5 years if the contract requires). For this we require the following: The manager and organisation name (include as much detail as you can) and start/finish dates (Including month and year). Please add the e-mail address and or phone number if you can. If there are any gaps in your work history of over 3 months, also include a character reference. People providing references should work in (or be retired from) a recognised profession, have known you for at least the last two years in a professional or personal capacity, and be able to confirm your identity if required. People providing references should not be related / involved with an applicant - by birth, marriage, relationship, or live at the same address. Reference 1Name* First Last Position* Referee's band* Organisation* Email address* Phone number*Start date Day Month Year End date Day Month Year Reference 2Name* First Last Position* Referee's band* Organisation* Email address* Phone number*Start date Day Month Year End date Day Month Year Reference 3Name First Last Position Referee's band Organisation Email address Phone numberStart date Day Month Year End date Day Month Year DeclarationsWTRThe WTR place a limit on the average number of hours per week that can be worked. If you are prepared to work more than the stipulated average hours per week (48 hrs) and therefore opt out of the WTR agreement, please select 'YES' below.* Yes - I opt out of WTR. No - I don't want to opt out of WTR. How did you hear about us?*Please select an optionSearch engine (Google, Yahoo, etc.)Social mediaRecommended by friend or colleagueBlog or publicationOtherGDPRI accept the terms outlined in the Privacy Policy.* Yes No In order to provide you with recruitment, payroll and related services we need to acquire and retain certain information about you as an individual. We will keep this information securely, only using it for the purposes outlined in our Privacy Policy, and in full compliance with the prevailing data protection legislation. Where necessary, in order for us to complete our service to you – such as ensuring you’re paid for the work you do – we will securely pass your personal information to approved third party service providers, such as payroll agencies. We only work with other businesses that are GDPR compliant, so you can rest assured your personal information is safe and secure. You must agree to our Privacy Policy in order for us to work with you. The full Privacy Policy can be viewed online, HERE. All of our company policies are available to view online, HERE.I agree to receive selected marketing communications from Bluestones Medical.* Yes No From time to time, we’d like to contact you to let you know more about the services we offer, share our latest career-related blog articles or news, or let you know about exclusive offers and promotions. We’d like to do this via email, post, SMS, phone and other electronic means. We’ll always treat your personal information with the utmost care and will never sell them to other companies for marketing purposes. We will not SPAM you or bombard you with marketing communications. You can always opt out of receiving these marketing communications at any point in the future, as all our emails include an unsubscribe link.DeclarationBy submitting this form, I hereby confirm that the information given is as complete as possible, true and correct and states that I am entitled to work through an agency in the UK. I agree that I will comply with all compliance procedures and ensure that all my documentation is present and correct. I understand that appointment to any position is conditional on satisfactory registration and qualification checks, and that any information disclosed on this registration form will be checked. Any offer of appointment may be withdrawn if you knowingly withhold information, or provide false or misleading information, and that registration may be terminated should any subsequent information come to light once you have been appointed.Signature*
