Bolff Healthcare Services Ltd

Application Form

PERSONAL DETAILS

Forename RUTH Other name: GBEMISOLA Title: MRS

Surname: ADESOMO Previous surname:

QUALIFICATION/S: DOCTOR RGN RMN RNLD ODP Support Worker yes Care Assistant Dentist
Dental Nurse Dental Assistant Midwife - Practising Yes No Other (Please specify):Care Assistant

Type of work required: Ad Hoc Locum Permanent position Permanent Yes (please email a copy of your up-to-date CV).

Current address line 1: NO 2 ROAD 3,OLUWATEDO AKOBO

Address line 2:

Town/City: IBADAN County:NIGERIA Post Code: 2001222

Tel No: Mobile No: 09169289239

Email address: [email protected]

Languages spoken: ENGLISH AND YORUBA Professional Reg. No: Expiry date:

Please bring your certificate to your NMC Revalidation date:

interview
Specialist registration (GMC only): -
Yes/No

Do you have professional indemnity insurance? ( Yes) No If yes details e.g. MDU/MPS/RCN/AODP/other (please specify):

Expiry date:

Nationality: NIGERIAN Passport No. Visa type: Work visa expiry date:
A10423500

Date of Birth: 10/01/1992 NI Number: 64160335109

Car Driver ( Yes) No Use of a car (Yes) No

Next of Kin: MR FALAJIKI ADEBOWALE Relationship to you: HUSBAND

Address (NO 2 ROAD 3,OLUWATEDO AKOBO. 2001222) Emergency telephone number (08132913902):

TRAINING and COURSES (since leaving secondary education)

NB: mandatory courses such as Moving and Handling should be listed on your competency check list and not here.
Mental Health workers – please add date of last Control and Restraint Training and bring your certificate to your interview

Name of Course Name and Address of School/College / University From To Qualifications gained

CARE GIVING TRAINING AA ELDERLY CARE,BESIDES NNPC FILLING 05-2022 05-2023 HEALTH CARE
STATION,AJANLA JUNCTION,AKALA ASSISTANT
EXPRESS,IBADAN,OYO STATE NIGERIA.
CARE GIVING TRAINING
CAREDEMY ONLINE TRAINING 01/10/2023 21/11/2023 CARE CERTIFICATE

HOSPITALITY TRAINING MIT COLLEGE PRETORIA SOUTH AFRICA 0111/2013 15/11/2013 HOSPITALITY
CERTIFICATE

JAVA TECHNOLOGIES NATIONAL INSTITUTE FOR INFORMATION 10/02/2010 27/05/2013 DNIIT HONOURS -
TECHNOLOGY,OFFA KWARA STATE NIGERIA SOFTWARE
ENGINEERING(JAVA
TECHNOLOGIES)

FULL EMPLOYMENT HISTORY and REFERENCES

Bolff Healthcare Services is required to carry out screening in accordance with the requirements of the role for which you have
applied. We require details of your FULL employment/unemployment history (since leaving full time education).

Please give details in the space provided for all periods of employment, self-employment, agency work, registered/ unregistered
unemployment, part time and voluntary work. Please be sure to give dates (month and year) and full work address details of
employers. For periods of registered unemployment, please give dates and full addresses of the Employment Service Job Centre
(ESJC).
Please explain any gaps in employment and please continue on another sheet is required.
References: Please give the names of your direct line managers for your last five years employment. If the organisation has a
Human Resources Dept please note, they will also be contacted.
Unless we hear from you to the contrary, we will contact your referees prior to your interview to ensure that the
registration process is completed as quickly as possible.
*If currently or previously working within the NHS, please state your last NHS Appraisal date and next one due:
Last NHS Appraisal Date: ____________________________ Next NHS Appraisal due date: ___________________

Please start from present or most recent employment and continue on another sheet if required.

Employer/Company/ Your Ward/ Type of From To Reason for leaving/

Establishment name and Official Unit/ Dept Organisation reason for gap in
address Job Title Month Year Month Year employment

1.A&A ELDERLY CARE HEALTH

CARE
ASSISTA HEALTH JUNE 2023 DECE 2023 TO ADD MORE
NT MBER KNOWLEDGE TO MY
Postcode: 200261 SKILL

Referee name (please impute full name): Referee job title: Manager Comments:
Toyin Afeez Adegoke

Referee work email: [email protected]

Telephone number: 08054139920

Employer/Company/ Your Ward/ Type of From To Reason for leaving/

Establishment name and Official Unit/ Dept Organisation reason for gap in
address Job Title Month Year Month Year employment

2.ASHA MICROFINANCE LOAN MICROFINAN JANU 2017 JANU 2023 AS A RESULT OF MY

BANK, ALLEN AVENUE OFFICER CE BANK ARY ARY PASSION FOR
IKEJA LAGOS CAREGIVING SERVICE.
Postcode: 100281

Referee name (please print full name): Referee job title: Branch Manager Comments:
Ayetomowo omololu shem

Referee work email: [email protected]

Telephone number: 08033208209

Employer/Company/ Your Ward/ Type of From To Reason for leaving/

Establishment name and Official Unit/ Dept Organisation reason for gap in
address Job Title Month Year Month Year employment

3. MEGARON PROJECTS SECRETA TO ADD KNOWLEDGE

LIMITED,ALLEN AVENUE RY TO MY SKILL
LAGOS STATE NIGERIA APRIL 2016 DECE 2016
MBER

Postcode: 100281

Referee name (please print full name): Referee job title: Comments:
Olagoke Oluremi Director

Referee work email: [email protected]

Telephone number: 08023036077

Employer/Company/ Your Ward/ Type of From To Reason for leaving/

Establishment name and Official Unit/ Dept Organisation reason for gap in
address Job Title Month Year Month Year employment

Postcode:

Referee name (please print full name): Referee job title: Comments:

Referee work email:

Telephone number:

Employer/Company/ Your Ward/ Type of From To Reason for leaving/

Establishment name and Official Unit/ Dept Organisation reason for gap in
address Job Title Month Year Month Year employment
5.

Postcode:

Referee name (please print full name): Referee job title: Comments:

Referee work email:

Telephone number:

Employer/Company/ Your Ward/ Type of From To Reason for leaving/

Establishment name and Official Unit/ Dept Organisation reason for gap in
address Job Title Month Year Month Year employment

6.

Postcode:

Referee name (please print full name): Referee job title: Comments:

Referee work email:

Telephone number:

Employer/Company/ Your Ward/ Type of From To Reason for leaving/

Establishment name and Official Unit/ Dept Organisation reason for gap in
address Job Title Month Year Month Year employment

7.

Postcode:

Referee name (please print full name): Referee job title: Comments:

Referee work email:

Telephone number:

Employer/Company/ Your Ward/ Type of From To Reason for leaving/

Establishment name and Official Unit/ Dept Organisation reason for gap in
address Job Title Month Year Month Year employment
8.

Postcode:

Referee name (please print full name): Referee job title: Comments:

Referee work email:

Telephone number:

Are there any areas you prefer not to work in? Yes/No ………. Please explain below.

Do you have any restrictions at all with your work practice? i.e., manual handling………. Please
explain below.

Do you have any annual leave booked with your current employer?.......Please explain below?

DECLARATION

I declare that the information given is, to the best of my knowledge, complete and accurate in all respects. I am legally permitted to work in the
UK. I have read, understood and agree to the conditions of engagement as provided by Bolff Healthcare Services of which I have been given a
copy. I understand that my registration is subject to satisfactory references. I undertake to inform you should my circumstances change (e.g.,
should I be convicted of an offence/receive a caution, have a change in health status, employment or professional body registration) since this
registration took place. I will inform you immediately, supplying written details if I am under investigation or suspended by my professional body,
Safeguarding or any employer at any time. I have also received and read the Working for Bolff Healthcare Services Ltd Handbook and I
understand and agree to the contents therein.
Signed………………ADESOMORUTHGBEMISOLA………………………………… Date……23/11/2023………………………

DATA PROTECTION/CONFIDENTIALITY

I acknowledge that this information may form the basis of a computerised personnel system, which I have access to as determined by The Data
Protection Act 1998 (full details of Bolff Healthcare Services Data Protection Policy are in the Bolff Healthcare Services (Handbook). I agree to the
passing on, to clients with whom I may be placed, (and other official bodies if requested as part of an investigation/audit) information held in
relation to me, by Bolff Healthcare Services.
I agree to respect the confidentiality of Bolff Healthcare Services its clients/workers and any information to which I may have access, at all times.
Signed………ADESOMO RUTH GBEMISOLA………………………………… Date…23/11/2023………………………

DEDUCTIONS

I understand and agree that on an annual basis I will have the payment for my annual DBS and up-date training deducted from my wages.
Signed……ADESOMO RUTH GBEMISOLA………………………………….. Date………23/11/2023……………

TRAINING

I understand that I will be required to attend the Bolff Healthcare Services induction day before I am placed to work. I also understand that I will be
required to attend an up-date training day on an annual basis. Should I fail to attend once a place has been booked for me, I understand that I will
be expected to pay the rate applicable at the time.
Signed……ADESOMORUTHGBEMISOLA………………………………………………………Date……23/11/2023……

EU REGULATIONS

I hereby agree to opt-out of the 48-hour working week limitation as laid down in the EU Working Time Regulations 1998. I understand that I may
end this agreement at any time by informing Bolff Healthcare Services in writing.
Signed……ADESOMORUTHGBEMISOLA…………………………………… Date……23/11/2023………………
I understand that in order to maintain effective registration with Bolff Healthcare Services, I will be required to update myself on the mandatory
subjects according to EU Regulations/other statutory requirements.
Signed…ADESOMO RUTH GBEMISOLA……………………………………………………… Date…23/11/2023

REHABILITATION OF OFFENDERS ACT

Because of the nature of the work for which you are applying, the provisions of section 4(2) of the Rehabilitation of Offenders Act (1974) do not
apply by virtue of the Rehabilitation of Offenders Act (1974) (Exceptions) order (Amendments) order 1986. Applicants are therefore required to
give information about convictions, which for other purposes, are ‘spent’ under the provisions of the Act. The information you give will be
treated in confidence and only taken into account where, in the reasonable opinion of Bolff Healthcare Services, the offence is relevant to the post
for which you are applying. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment, if the
offence is not declared, but later comes to light.

Have you at any time been convicted of a criminal offence or cautioned by the police? YES NO
If ‘YES’ please complete a Statement of Conviction form. Have you enclosed this with your application YES NO
Under UK legislation we are required to perform an enhanced DBS check before placement and annually thereafter.

Do you agree to have an enhanced DBS check at your expense? YES NO

If you hold a DBS certificate registered with the DBS update service,
do you give consent for Bolff Healthcare Services to check this online? YES NO

Signed…ADESOMO RUTH GBEMISOLA…………………………Date…23/11/2023…………………………………………………

How did you hear about Bolff Healthcare Services?

Word of mouth Window advert Local newspaper advert Bolff website Search Engine (please
state which one and what you ‘searched’ for e.g. nursing/care agency) ………………………………………..
Other please specify…………………………………………………………………………………………………….