Please make sure you:

• Answer all the questions on this form • Complete this form in CAPITAL letters • Use black ink

Application Form HCA

1. Your personal details

Title: Address:

First name(s):
Name preferred to
be known by:

Surname: Post code:

Daytime phone
Date of birth: number:
National Insurance
Number: Mobile number:

E-mail address:

Do you have a full UK Driving Licence? Yes: No:

2. Your next of kin details

Name: Name:

Relationship to you: Relationship to you:

Address: Address:

Post code: Post code:

Daytime phone Daytime phone
number: number:

Mobile number: Mobile number:

3. Your right to work

Your nationality:
Your eligibility to work in the UK:
I am eligible to work in the UK and do not require a work permit I have a valid work permit to work in the UK
I have a valid biometric visa which permits me to work in the UK I need to obtain a work permit to work in the UK
4. Your employment history

Please supply details of your full working history.

• Include ALL gaps in your work history and ensure that you include any periods of unemployment
• A full CV is acceptable provided it lists your history from qualification and includes details of the months and years.

Date from Date to Employer’s name and address Duties and grade Reason for leaving
DD/MM/YY DD/MM/YY
 5. Your professional skills

Please tick boxes , with clinical areas you have expertise in:
Nursing Homes Learning Disabilities Elderly Care Homecare

Community Mental Health Supported Living Residential Care

Dementia Challenging Behaviour Hospital Day Care Centres

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6. The work you want

When are you Which areas do you

available to start? wish to work?

Part time Days Weekdays

Full time Nights Weekends

Residential Nursing Home

Other, please specify

7. Your professional conduct

Have there been any proceedings of medical negligence or professional misconduct against you and have you ever Yes: No:
been suspended or dismissed?
Are you aware of any professional conduct/competence enquiries being considered against you? Yes: No:

Please give us information about the type of work you want so that we can find the right work for you.

If “YES” please supply details (use separate sheet if required):

REHABILITATION OF OFFENDERS ACT

Because of the nature of the work for which you are applying, Section 4(2), and further Orders made by the Secretary of State under the
provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 197 applies. Applicants are therefore required
to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will
be completely confidential and will be considered only in relation for positions to which the order applies.
Have you at any time been convicted of an offence? Yes: No:
If “YES” please supply details (use separate sheet if required):

DBS
Have you had a DBS Enhanced Disclosure conducted in the last 6 months? Yes: No:
Are you a member of the DBS update service? Yes: No:
If “YES” please enter details below:

Date: Issue number: Issuing body:

I give my consent for Honeywell Health Care to check that I am registered with the DBS update service and to check the status of my DBS. I
have provided Honeywell Health Care with my DBS information to verify online.

Print name Signature Date

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 8. Your reference details
• Please supply the names and work addresses of at least 2 clinical professional referees.
• All references must relate to employment over the last 3 years.
References must be provided by an employer or work colleague for work placements covering the last three years. If you have not worked before
please give the name and address of a member of your school, college or university.

Do we have permission to contact your referees prior to an interview? Yes: No:

Reference 1

Referee name: Hospital:

Position:

Start date: Post code:

End date: Email address:

Contact phone In what

number: capacity has
this person
known you?
Reference 2

Referee name: Hospital:

Position:

Start date: Post code:

End date: Email address:

Contact phone In what

number: capacity has
this person
known you?

Reference 3

Referee name: Hospital:

Position:

Start date: Post code:

End date: Email address:

Contact phone In what

number: capacity has
this person
known you?

Under the Conduct of Employment Agencies and Employment Business Regulations 2003, Honeywell Health Care Consultancy Limited may be required to
make this reference confidentially available to prospective employers. Unless expressly stated otherwise, we shall assume that we have your permission to do
so.

9. Your induction to us

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 9. Your induction to us

Referrals Recommend a friend

How did you har about us?

If referred, please let us know who referred
Recommend a friend

You may know someone who may be interested in working with us. Please ask for our company referral fee structure.

Name: Grade/Spec: Contact No:

Name: Grade/Spec: Contact No:

Name: Grade/Spec: Contact No:

10. Fatigue & professional practice

Under section 19 of the NMC code of conduct, it highlights all the relevant details regarding the management of risk. As an agency worker, you should
consider at all times the impact of multiple jobs and your working hours on your ability to practice safely. If you do back to back shifts as an agency
worker (one shift for one organisation and a second for another ) it is our opinion you will be in breach of the NMC code and risk being referred to the
NMC as your actions are not managing your level of risk to patient safety. We will not accept back to back shifts in our organisation and expect you
at all times to be vigilant about the impact of fatigue on your professional practice.
I understand this and will at all times be mindful of the requirements under the NMC code in relation to this. Yes: No:

Print name Signature Date

11. Your bank details

We pay your wages directly into your bank account via BACS on a weekly basis.

Bank name:

Account holder name:

Name of Limited Company

(if applicable):

Sort code:

Account number:

Please select one of the following options:

I wish to be paid through a limited company (please enclose relevant details) Yes:
OR
I wish to be paid P.A.Y.E (Please enclose your P45 if we are your main employer) Yes:

Read all the following statements carefully and tick the one box that applies to you.

A. This is my first job since 6 April and I have not been receiving taxable Jobseeker’s Allowance or taxable Incapacity Benefit or a state or
occupational pension. Yes:
OR
B. This is now my only job, but since last 6 April I have had another job, or have received taxable Jobseeker’s Allowance Yes:
or Incapacity Benefit. I do not receive a state or occupational pension.
OR
C. I have another job or receive a state or occupational pension. Yes:

Print name Signature Date

12. Your declarations

1. HEPATITIS B
I have been advised at the registration office of the importance of having the Hepatitis B vaccine. I acknowledge that I have been/am being vaccinated against Hepatitis B
and will continue to maintain my immunity. I accept responsibility for my decision and I will ensure that I take all precautions to avoid contracting the illness and avoid
accepting work within environments which are hazardous.

2. TERMS & CONDITIONS

I confirm that the information given in this application is, to the best of my knowledge, true. I am permitted to work in the UK.
I understand that my registration is subject to the receipt of sufficient satisfactory references and an enhanced disclosure from the Disclosure and Barring Service (DBS).
I understand that Honeywell Health Care can contact any of my past or current employers listed on my CV / Work History for a reference to make up the required three
years referencing history.
I undertake to inform Honeywell Health Care should I be convicted of an offence in the future.
I undertake to inform Honeywell Health Care immediately if I am engaged through their introduction, including the offer of permanent employment following a temporary assignment.
I am clear that Honeywell Health Care cannot guarantee assignments and that they have no responsibility to pay for hours not worked no matter the situation.
I have read, understood and agree to the conditions of work for temporary nurses, of which I have been given a copy.
I will update Honeywell Health Care if there is an investigation relating to my NMC registration immediately.

3. INDUCTION
I have received a copy of the induction information letter and received a copy of the Honeywell Health Care Agency Worker Handbook. I have read, understood and agree
to abide by its contents, including the conditions of registration and all applicable Policies, Procedures and Guidelines of Honeywell Health Care When Honeywell Health
Care inform me of updates to this handbook from time to time, I will read these changes before commencing any further shifts through Honeywell Health Care

4. BANK DETAILS
I have completed my bank details and confirm they are complete and correct. I hereby understand that any incorrect or incomplete details can result in a delay of my payment.

5. DATA PROTECTION
I agree that Honeywell Health Care retain the right to hold this application and any other data required to process it and to pass on to any authorised third party the details
held within, also to retain these details for as long as reasonably necessary in accordance with the Data Protection Act.
In accordance with the Data Protection Act to agree to allow Honeywell Health Care Consultancy Limited to send you regular updates of suitable vacancies & recruitment
information/services whether by letter, email, text or telephone we must request that you indicate below your acceptance of these forms of communication. Also that you
give permission to Honeywell Health Care Consultancy Limited to carry out a credit reference check via a credit agency where applicable.
AUDIT
I understand my documents will be audited for compliance by external auditors for relevant NHS frameworks and I consent to that. I also consent to my documents being
audited under any sub-contracting arrangement to deliver services to a managed service provider for a relevant framework agreement.

6. CONFIDENTIALITY
As a Temporary Worker I agree to:
• keep confidential all information relating to Work Results, Intellectual Property Rights in the Work Results, and Honeywell Health Care, the Client’s or any other Honeywell
Health Care client’s business and affairs (including, for the avoidance of doubt, Payment Rates) (“Confidential Information”) which may become known to me in connection
with the supply of the Services;
• not use any Confidential Information except for the purposes of performing the Services;
• without delay enter into any and all assignments of Intellectual Property Rights (relating to the Work Results) or confidentiality undertakings that Honeywell Health Care
or the Client may require me to enter into;
• not without the Client’s express written permission remove from the Client’s premises any material containing any Confidential Information; and
On request, return to Honeywell Health Care (or as Honeywell Health Care may direct) all material in my possession or control and belonging to the Client or Honeywell
Health Care and/or containing Confidential Information.

7. RESPONSIBILITY OF COMPLIANCE
Many of your compliance items need to be reviewed annually. It is your responsibility to ensure that your file is in date at all times. If any of your compliance items lapse,
we will not be able to offer you any work and may need to re-register you completely.

By signing below you confirm that the information that you have provided in this form is complete and true and that you agree with the declarations above.

8. WORKING TIME REGULATIONS

For the purpose of the Working Time Regulations 1998 (as amended), I consent to work in excess of an average of 48 hours per week. I understand that I may withdraw
this consent by giving Honeywell Health Care not less than one months’ notice in writing. I understand that my registration with Honeywell Health Care can be terminated
at any time following unsatisfactory work reports.
Opt in Opt out

Signature Date
 13. Equal opportunities form

Synergy Medical is committed to equal opportunity for all. To help us achieve this please complete the following questionnaire.

1. The postcode of my current address is:

2. Age Range:

Under 20 20-29 30-39 40-49 50-59 60-65 65+

3. Disability

Do you consider yourself to have a disability as defined in the Discrimination Act 1995? Yes: No:
Please provide any information you consider to be relevant, to assist us in making appropriate adjustments for you:

4. Ethnic background. Please tick the box you feel most appropriately identifies your ethnic origin

Asian Black Chinese Dual Heritage White

Bangladeshi African Chinese White & Asian English

Indian British Other White & Black African Irish

Pakistani Caribbean White & Black Caribbean Scottish

Other Other Other Welsh

Other

5. My nationality is

I am a citizen of the European Union/UK Other (please state)

6. Gender - I identify as:

Female Male

Transgender Other

I prefer not to say

7. Religion

I would describe my religious background/belief as (please write in the box)

I have no religious beliefs I prefer not to say

8. Sexual Orientation

Heterosexual Homosexual

Bisexual I prefer not to say

Thank you for taking the time to complete this form.

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 14. Induction information
Welcome to Honeywell Health Care

Thank you for choosing to work with us. We have a reputation for supplying the highest quality of agency staff to a wide range of healthcare insti-
tutions and we recognise that our success depends on you.

Working together with you, we aim to make your experience with us a positive and rewarding one, one where you feel part of our valued team.

We have designed our Agency Worker Handbook to give you guidelines of what we expect from you and what you can expect from us. It sets out
the standards you are expected to adhere to and it outlines the clear policies and procedures to follow.

Please read it carefully it and the information provided. It includes a number of guidelines and standards required under the Framework Agree-
ments issued by the NHS. It is important you understand everything covered in it. If there are any points you do not understand or if you have any
feedback on how we can improve the handbook please let us know.

Our Agency Worker Handbook and our Policy and Procedures are available on our website but some are summarised below:

• Please make sure you arrive on time for your placement, or preferably 10 minutes early. If you are running late, you must ring us as soon as pos-
sible and advise us of this so that we can ring the client.
• You are our representative at the client. Please ensure that you perform your expected duties professionally and willingly at all times.
• If you cannot make your shift, you must give adequate notice in order for a replacement to be arranged.
• Honeywell Health Care will only pay on receipt of an authorised timesheet. Please ensure you submit your timesheet to us every week. Weekly
pay-ments are made provided the timesheet arrives by Tuesday at 12 noon for payment on Friday. We cannot guarantee that your timesheet has
been received unless it is physically brought to us.

If for any reason you are unhappy with any aspect of the service that Honeywell Health Care provide please feel free to contact our HR Dept.

Please take some time out before starting your first placement with us to read your Terms and Conditions of employment. This information should
provide you with all of the reference material you may require. Please feel free to ask your contact within the organisation if there is anything that
you are unsure of, as we are always here to help, 24 hours a day.

Thank you and welcome aboard.