RMN APPLICATION FORM

Employment History

Please provide us with information with your most recent employer and previous in the last 10 years.
Please ensure you account for any gaps in employment history longer than one month.

Education History and Qualifications

Details of Additional Training or Courses Undertaken

Rehabilitation of Offenders Act 1974 / Criminal Record Declaration.

Due to the nature of our organisation and the post you are applying for, posts resulting from this registration
process are exempt from the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption
Order 1975). This means that applicants are entitled to withhold information about convictions, which for other
purposes are “spent” under the provision of the Act in the event of employment, any failure to disclose such
convictions could result in dismissal or disciplinary action. All information disclosed will be kept in confidence
and will only be used in connection to the post/role you are applying for. In certain instances, this information
may be shared discreetly with relevant hiring managers

I CONSENT TO MY AGENCY CHECKING THE DETAILS I HAVE PROVIDED AGAINST THE VARIOUS DATA SOURCES IN ORDER TO VERIFY MY INDENTITY AND PROCESS THIS APPLICATION. THESE DETAILS MAYBE USED TO ASSIST OTHER ORGANISATION SUCH AS CRB, NMC IN IDENTITY PURPOSES.

Please note that providing a positive response to the above questions does not necessarily exclude you from working with Manilla Healthcare Staffing. Failure to provide response to the above information will result in your engagement with Manilla Healthcare Staffing (MHS) being terminated with immediate effect.

References

To work with Manilla Healthcare Staffing (MHS), we require two references.
References are required to cover a minimum period of three years.

Reference 1

Reference 2

Reference 3

Applicant Declaration.

1. If I am charged or cautioned following my application, I understand that I must inform Manilla Healthcare
Staffing (MHS), immediately.
2. If I cannot provide a valid DBS certificate registered with the Update Service, I authorise Manilla Healthcare
Staffing (MHS), to undertake an Enhanced Disclosure and Barring Service Check.
3. I authorise Manilla Healthcare Staffing (MHS), to carry out checks with referees for both employment and
education history.
4. I am not currently subject to any safeguarding investigation and have not previously been subject to
disciplinary action due to alleged misconduct. I am not currently under investigation or suspended by my
professional regulatory body (NMC, HCPC etc) or by my current or previous employer. I will inform Manilla
Healthcare Staffing (MHS), should this cease to be the case.
5. I agree to read and understand all care plans before acceptance and commencement of shifts. I will
immediately raise concerns with Manilla Healthcare Staffing (MHS), if I do not feel suitable.
6. I will request and complete an induction prior to the start of my shift in a new location.
7. I confirm that I have received the Staff Handbook and agree to abide by the terms set out in it.
8. I understand and consent to my personal details being stored and handled by Manilla Healthcare Staffing
(MHS), in accordance with the Data Protection Act 2018. I permit my data to be shared with relevant
authorities and organisations, as well as for audit/review purposes.
9. I understand that it is my responsibility to not work more hours than legally permitted by my RTW status, i.e.
not working more than 20 hours per week during term time if I am on a Student Visa.
10. Aside from any condition(s) declared on my Occupational Health Questionnaire, I am not aware of any
medical condition which would inhibit or affect my employment or performance.
11. I agree to provide accurate information regarding my working history in relation to the Agency Worker
Regulations (AWR). Should I reach the qualifying period under the AWR, I shall provide any documentation
requested as evidence.
12. I declare that the information listed in this application is truthful, complete and is not intended to mislead. If
information is proven to be inaccurate, false or misleading, I understand that Manilla Healthcare Staffing
(MHS) may cease to offer me work with immediate effect. I acknowledge that Manilla Healthcare Staffing
(MHS), reserves the right to claim for recovery of any payments I have received and for loss of earnings due
to omission of or misleading information.
13. I authorise, where applicable, Manilla Healthcare Staffing (MHS), to undertake necessary Right to Work
checks with the Home Office to ascertain my eligibility to work in the UK

Working Time Regulations (WTR) Opt-Out Declaration.

“I agree that I may work more than an average of 48 hours a week. If I change my mind, I will give my employer no less than 14 days’ notice in writing to end this agreement.”

Confidentiality Declaration.

Submitting this application form implies your acceptance to our Code of Confidentiality which is outlined in the staff handbook. Under no circumstances must information relating to an identifiable client(s) be divulged or shared with anyone other than senior management at Manilla Healthcare Staffing (MHS). You are not to disclose any information to family, friends or colleagues (unless in a professional capacity relevant to the execution of your role).
As a temporary worker for Manilla Healthcare Staffing (MHS), you shall not disclose to third party companies, the details of our clients or nature of the work completed. If you are concerned about the information you have obtained, please make an appointment to speak in private with your manager.
Failure to observe and follow the above will be regarded as serious misconduct and may result in your removal from our database.
“I have read and understand the above and agree to abide by the contents therein.”

HEALTH DECLARATION

Do you or have you at any time suffered from any of the following?

I authorise Manilla Healthcare Staffing to pay my weekly wages into the above bank account and I will notify Manilla Healthcare Staffing if changes occur to my details.