Please check the registration requirements then fill in the online application form.
Required for your I.D badge. This can be a selfie!
Fully completed and hand signed
We must have evidence of MMR, Hep B, TB and Varicella immunity.
Name, contact number and e mail of every manager covering the last 3 years
How did you hear about Dove Caring?
Please indicate work type
NMC Pin No.
RCN / Union Number
Please answre yes or no to the following
Do you hold a current UK driving licence?
Do you own a car?
Next of Kin
Employment History (Up to 5 years)
REHABILITATION OF OFFENDERS ACT
Due to the nature of the work you are applying for, this post is exempt from the provision of section 4 (2) the
rehabilitation of offenders act 1974 by virtue of the rehabilitation of offenders act 1975 (exception) order 1975
applicants are therefore, not entitled to withhold information about convictions which for any other purpose are "spent"
under the provisions of the act and in the event of employment, any failure to disclose such convictions could result in
dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in
relation to an application for the positions where the order applies and should be entered at the end of any particulars
you give in support to this application.
Do you have any criminal convictions?
If yes, please give details
I understand my GP may be contacted in regards to my application, and I may have to incur a cost, as applied by my GP (please tick the box to confirm that you agree to the statement)
PLEASE PROVIDE EVIDENCE OF PROFESSIONAL QUALIFICATIONS, IMMUNISATIONS AND MANDITORY
Have you ever suffered from or been treated for the following? Your medical history will not effect your application.
Heart / circulatory, Hypertension
Asthma / Hay fever
Bronchitis / Pneumonia
Headaches / Migraines
Psychiatric illness / Depression / Anxiety
Dermatitis / Skin sensitivity
Eczema / Psoriasis
Back injury / back pain
Hepatitis / Jaundice
Are you registered disabled?
If yes, registration number
Are you currently receiving any medication or treatment from your GP?
Do you have any other physical disability or health concern that may affect your ability to carry out assignments?
Work Specialism / Preference
Preferred Work Location
Account Holders Name
I authorise Dove Caring LTD to pay my weekly earnings directly into the bank or building society whose details I have given above. I confirm that I will notify Dove Caring LTD in writing of any changes to these details.
I have read and understood the Dove Caring LTD PLC OPT OUT OF 48 HOUR WORKING WEEK AGREEMENT as described in Rule 72 of the policy and procedures found at and I hereby consent that the working week limit shall not apply to my assignments in accordance with paragraph 3 of the agreement. I understand that under paragraph 4, WITHDRAWAL OF CONSENT, I can end this agreement by giving the Employment Business 14 days notice in writing.
If you require to be paid through a UK Limited or Composite company, then the following details are required. N.B. Certificates of registration will be required.
Company Reg No.
Company VAT No. (If VAT payments required)
For Office Use Only
I DECLARE THAT ALL THE STATEMENTS AND PARTICULARS ARE TRUE AND COMPLETE
(Please tick the box to confirm that you agree to the statement)
Please answer the following questions yes or no
Have you ever had any problems with your joints, including pain, swelling or stiffness?
Do you have any difficulty in moving rapidly over short distances?
Would you have difficulty looking over either shoulder?
Do you need to wear glasses or contact lenses?
Do you have any difficulty with your eyesight which is not corrected by glasses or contact lenses?
Have you any problems working with Visual Display Units?
Have you any problems working in confined spaces/using lifts?
Do you have any difficulty hearing normal conversation?
Are you taking any medication that makes you dizzy or drowsy?
Do you have a medical condition affected by changing sleeping patterns or affecting day time sleep?
Have you suffered from any alcohol or drug related illness or had an alcohol or drug problem?
Are you having or awaiting any treatment at the moment?
What was the date of your last x-ray?
Are you receiving Medicines, Pills, or Tablets from a doctor or on prescription?
Have you ever suffered from any of the following?
Heart Problems/Circulatory Illness/Hypertension
High or Low Blood Pressure
Epilepsy/Fainting Attacks/Blackouts/Fits/Sudden Collapse
Psychiatric Illness/ Anxiety/Depression
Back Injury/Back Problems/Back Pains
Recurrent Infections e.g Sore throats/Ear Infections/Eye Infections
I declare the statements are true end complete to the best of my knowledge and belief. I understand that my General Practitioner may be consulted with my prior consent.
I declare that the answers given with this Declaration of Health on this form are true and complete to the best of my knowledge and belief. I understand that making false statements or failure to declare health problems could lead to my removal from Dove Caring LTD. I give Dove Caring LTD permission to contact my GP to obtain further information if necessary
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 at least two satisfactory references and enhanced disclosure from the Criminal Records Bureau. I undertake to inform Dove Caring LTD should I be convicted of an offence in the future. I undertake to inform Dove Caring LTD immediately if I am engaged through their introduction, including the offer of permanent employment following a temporary assignment. I agree to respect the confidentiality of patients and any other information I may have access to, at all times. I am clear that Dove Caring LTD 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 have received a copy of the Induction information letter and can confirm that I am aware that more detailed information on the staff handbook and Policy and procedure can be obtained directly from Robin recruitment.
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 Dove Caring LTD not less than three months notice. I understand that my registration with Dove Caring LTD can be terminated at any time following unsatisfactory work reports.
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.
I agree that Dove Caring LTD retains 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.
I understand that due to my occupational exposure I may be at risk of acquiring Hepatitis B infection. I have
been given the opportunity to be immunised.
Dove Caring LTD have advised me of the importance of Hepatitis B vaccination, MMR (Measles, Mumps,
Rubella) and supplied me with information on the vaccine.
I am aware that in order to ensure immunity I am required to receive two MMR immunisations or have a
blood test to check my immunity to MMR.
However, I decline immunisation at this time due to health/non-responder status, cultural, religious reasons
or personal reasons. I understand that by declining the vaccine I may continue to be at risk.
I accept responsibility for my decision should I contract the illness from working in the healthcare environment. In my duty of care I will also ensure I take every precaution, as per local policies and procedures. Paying particular attention to sharps and the use of P.P.E to avoid contracting the illness
Signed for Hepatitis B
Signed for Measles, Mumps and Rubella
Please enter full name below
do hereby declare that I have previously contracted Varicella (Chicken Pox) and / or Herpes Zoster (shingles).
CRB Disclosure Application
Surname at birth (if different)
Forename at birth (if
If you have been known by any other name please detail below
Known by Forename(S)
At current address since
Previous Address (if less than 5 years)
Date of Birth
Town of Birth
Do you have non-spent convictions?
Driving License Number
Country of Issue
Dove Caring Ltd, NVB Enterprise Centre, 6 David Lane, Nottingham, NG6 0JU
Mob: 07826 737 570
Tel: 01159 648 243
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