Application Form

To join our team, kindly fill out the application form below

Application Form

Application Form

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- Personal Details
Name
N/A

-Select-

Title First Name Last Name
Marital Status
N/A
Maiden Name
N/A
Nationality
N/A
Country of Birth
N/A
DOB
N/A

dd-MMM-yyyy
Email
N/A
Address
N/A

Street Address Address Line 2 City State/Region/Province Postal / Zip Code

-Select-

Country
Phone Number
N/A
Mobile Number
N/A
National Insurance Number
N/A
Current UK Driving License?
N/A

-Select-

Please complete this section if you are not a British Citizen

	Yes/No
Do you have a UK Residence Permit?	-Select-

Are there any UK immigration control restrictions limiting your length of stay, conditions of stay or freedom to? work in the UK?
N/A

-Select-
What hours are you looking for?
N/A
Date available to start?
N/A

dd-MMM-yyyy

Rehabilitation of Offenders Act 1974

By the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, the provisions of Section 4.4 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such a kind as to enable the holder to have access to persons in receipt of such services during his normal duties. Your answer to the following question should be include any spent and unspent convictions.
Have you ever been convicted of a criminal offence, cautioned, served a sentence or had a suspended sentence?
N/A

-Select-
If yes, please explain
N/A
Working Time Regulation

Under the working time regulations (WTR), Blizz Care working time (including placements and services provided personally to anyone else) should not exceed 48 hours per week. (average over the period 17 weeks).Night duty hours must not exceed 11 hours in the 24hours however, if you wish to wave this right, you are required to declare this on joining Blizz Care and the Health questioner form most be completed. Blizz Care workers can withdraw the option to work in excess of the 48 hours per week at anytime by providing 2 weeks written notice. If you chose not to sign this agreement you will not suffer any detriment.

I hereby confirm I am willing to opt out of the Working Time Directive.

I understand that I can opt out of this agreement at anytime on the condition that I provide Blizz Care Two Weeks ‘notice.
Name
N/A
Date
N/A

dd-MMM-yyyy
Signature
N/A

E-Signature Field
Clear
CONFIDENTIALITY

All staff should agree to the following confidentiality agreement by signing the application form. Any information concerning patient, their treatment is strictly confidential. Any breach of these may result in the termination of your engagement and could result in disciplinary action.
Signature
N/A

E-Signature Field
Clear
Declaration

I declare that I have answered the above questions fully and honestly and I know of no reason why I may not be suitable for the duties introduced to me by Blizz Care. I realise that any false or in-complete statement of my part will render me liable to disciplinary action or dismissal. I also understand that my details will be held in a staff database for administration purposes, and I understand that Blizz Care will share my details with their client and other parties. I give permission for my data to be shared with relevant third party as may be required in line with the job
Signature
N/A

E-Signature Field
Clear
Date
N/A

dd-MMM-yyyy

GDPR
General Data Protection Regulation ((EU) 2016/679 (GDPR).

PERMISSION TO DISCLOSE SENSITIVE PERSONAL DATA

(please type in capital)
Name
N/A
Contact Address
N/A
Post Code
N/A
Job Role
N/A
- I consent to the following sensitive personal data about me being disclosed - give explicit details: Personal Information (Name/DOB/Mobile number/email address/NI Number/Address) DBS Details, NMC PIN, Passport Details, Right to Work Documents, Training Detail, Health Information and all other information relevant information for the purpose of my employment.
- For these purposes - give explicit details:
  
  Temporary Workers (Nurse, Hca, Support Worker) at Care Homes/Hospital/Community
- I understand that Blizz Care will process my sensitive personal data strictly in accordance with the Data Protection Act 1998. I hereby give my consent to the disclosure of my personal data for the above purposes, to the persons named.
Signature
N/A

E-Signature Field
Clear
Date
N/A

dd-MMM-yyyy

BLIZZ CARE - TERMS OF ENGAGEMENT
1. DEFINITIONS

In these Terms of Engagement the following definitions apply:

Assignment - the period during which the Temporary Worker is supplied to render services to the Client;

Client - the person, firm or corporate body requiring the services of the temporary Worker together with any subsidiary or associated company as defined by the Companies Act 1985;

Temporary Worker means trained Nurse, Healthcare Assistant, Chef, Domestic, Kitchen Assistant or other temporary worker who agree to and is provided with a copy of these terms of engagement.

Unless the context otherwise requires, references to the singular include the plural and references to the masculine include the feminine and vice versa.

The headings contained in these Terms are for convenience only and do not affect their interpretation
2. THE CONTRACT

These terms constitute a contract for services between the Employment Business and the Temporary Worker and they govern all Assignments undertaken by the Temporary Worker. However, no contract shall exist between the Employment Business and the Temporary Worker between Assignment.

For the avoidance of doubt, these Terms shall not give rise to a contract of employment between the Employment Business and the Temporary Worker. The Temporary Worker is engaged directly by the Client and is subject to the Client’s contractual requirements and is covered by the Client’s liability insurance.
The Employment Business engages the Client in order to procure the services of the Temporary Worker for the term of the contract.

No variation or alteration of these Terms shall be valid unless approved by a director of the Employment Business in writing.
- 3. ASSIGNMENTS
  
  3.1 The Employment Business will endeavour to obtain suitable Assignments for the Temporary Worker to work in fields specified by the Temporary Worker on his/her application forms (updated as necessary). There is no charge for this work finding service although the Employment Business does, from time to time, provide services for which a charge is made. Details of these are available on request.
  
  3.2. The Temporary Worker acknowledges that the nature of temporary work means that there may be periods when no suitable work is available.
  
  The Temporary Worker further agrees that suitability shall be determined solely by the Employment Business and that the Employment Business shall incur no liability to the Temporary Worker should it fail to offer opportunities to work.
  
  The Temporary Worker shall not be obliged to accept any Assignment offered by the Employment Business.
  
  The Temporary Worker may not, under any circumstances, introduce any other person to supply the services in place of the Temporary Worker.
  
  If, during the course of the Assignment or within certain periods after the end of an Assignment or after an introduction where no assignment took place, the Client wishes to employ the Temporary Worker directly (or assist another body to employ the Temporary Worker directly), the Temporary Worker acknowledges the Employment Business will be entitled either to charge the Client an introduction fee or a period of extended hire unless, for any reason, the Temporary Worker was introduced to the Employment Business by the Client.
4. FEES AND CHARGES

4.1 Unless otherwise agreed the Employment Business shall pay the Client’s fees relating to the hours worked by the Temporary Worker. The Client will only pay the Employment Business invoices that have corresponding authorised timesheets.
5. ASSIGNMENT TIMESHEETS

At the end of each week of an Assignment (or at the end of the Assignment where it is for a period of one week or less or is completed before the end of a week) the Employment Business shall invoice the Client the agreed fees that relate to a corresponding timesheet for all the work carried out by the Temporary Worker. Payment will not be made without fully authorised timesheets being submitted.

The Temporary Worker working time shall only consist of those periods during which he is carrying out activities or duties for the Client as part of the Assignment. Time spent travelling to the Client’s premises, lunch breaks and other rest breaks shall not count as part of the Temporary

Worker’s working time for these purposes.
6. CONDUCT OF ASSIGNMENTS

6.1. The Temporary Worker is not obliged to accept any Assignment offered by the Employment Business but if he/she does so, during every Assignment and afterwards where appropriate, he/she will:- a) Co-operate with the Client and/or the Client’s staff, accept reasonable instructions and accept the direction, supervision and control of any responsible person in the Client’s home or organisation; b) Be present at such times as may be stipulated by the Client and unless arrangements have been made to the contrary, to conform to the normal hours of work agreed at the premises where the assignment is to be carried out; c) Observe any relevant rules and regulations of the Client’s establishment (including normal hours of work) to which attention has been drawn or which the Temporary Worker might reasonably be expected to ascertain; d) Take all reasonable steps to safeguard his own health and safety and that or any other person who may be present or be affected by his actions on the Assignment and comply with Health and Safety policies and procedures of the Client and the Employment Business; e) Not engage in any conduct detrimental to the interests of the Client; f) Not at any time divulge to any person, nor use for his own or any other person’s benefit, any confidential information relating to the Client’s or the Employment Business’ employees, business affairs, transactions or finances; g) Act in a professional and courteous manner; h) Be responsible for the provision of a uniform and any necessary equipment; i) Co-operate with the Employment Business’ staff and accept their direction, supervision and control.

6.2 If the Temporary Worker is unable to attend work during the course of an Assignment he should inform the Client and the Employment Business within Six (6) hours before the assignment to enable alternative arrangements to be made.
7. TERMINATION

Before commencing any assignment, the Temporary Worker must provide the Employment Business with confirmation that he has (1) The required Right to Work, (2) not been convicted of or cautioned in relation to any criminal offence.

In the event that the Temporary Worker is charged with or cautioned in relation to any criminal offence he must inform the Employment Business immediately and provide regular reports about the progress of the proceedings.

The Temporary Worker will fully co-operate with the Employment Business in relation to any criminal record checks which The Employment Business is required to carry out.

Before commencing any assignment the Temporary Worker must inform the Employment Business about any complaint made against him/her that is relevant to their professional competence, standing or conduct.

In the event that the Temporary Worker becomes the subject of a complaint he/she must inform the Employment Business immediately and provide regular reports about the progress of proceedings.
The Employment Business will inform the Temporary Worker about any complaint made against him/her that is relevant to his/her professional competence or conduct.

The Employment Business will inform the Temporary Worker about any complaint made against him/her that is relevant to his/her professional competence or conduct.
Unless otherwise agreed the Employment Business and the Client may, without prior notice or liability, terminate the Temporary Worker Assignment at any time.

If the Temporary Worker does not inform the Client of the Employment Business should they be unable to attend work during the course of any Assignment this will be treated as termination of the Assignment by the Temporary Worker unless the Temporary Worker can show that exceptional circumstances prevented informing the Employment Business of the absence.
8. SPECIAL PROVISIONS

The Temporary Worker and the Employment Business must provide the Client with all requested proof of qualifications, references, recent photographs (for identification purposes), access to health records and medical registrations as may be requested in order for the Client to satisfy itself that the must provide is fit to be supplied to Clients.

The Temporary Worker accepts that the Employment Business is or may be required to handle/process this (and other personal information as reasonably requested from time to time) and may need to share such information with its agents or third parties as part of performing its duties.

The Temporary Worker recognises such obligations on the Employment Business and hereby consents to the handling, processing and divulging (whether in the UK, the European Union or elsewhere) of such information as may be necessary for the Employment Business (or its agents) to perform its duties.
In the situation where the Temporary Worker is a qualified nurse, the Nurse should ensure that her registration with the NMC remains effective at all times and that she complies with the NMC Professional Code of Conduct during every Assignment.

In the situation where the Temporary Worker is a Carer without relevant National Vocational Qualification, the Carer shall register for the relevant NVQ within the first six months of commencing an Assignment with the Employment Business and shall complete the qualification within three years.

In all cases Temporary Worker with professional qualifications and who rely thereon for agency work must ensure full and current compliance with the appropriate professional requirements.

The Temporary Worker shall advise the Employment Business immediately if offered any employment or engagement by the Client or any third party to whom she is introduced by the Client and is also requested to provide details to the Employment Business or any remuneration offered.
The Temporary Worker is required to advise the Employment Business of any medical condition or any change in state of health that could impact upon their ability to carry out Assignments or their eligibility for Assignments.

The Temporary Worker must follow and co-operate fully with the formal induction procedure of the Employment Business and undertake any training specified by the Employment Business.

Throughout each Assignment the Temporary Worker must comply with the Employment
Business’ policies and procedures on standards of conduct and all organisational matters, as set out in the Employment Business’ handbook, and on the safe handling of client money and property.

The Temporary Worker hereby agrees not to be involved in assisting in the making of, or benefiting from, the Will or Codicil of any patient whom the Temporary Worker is supplied to assist, nor will the Temporary Worker become involved in any other legal documentation concerning the Client’s affairs.

At all times during an Assignment the Temporary Worker shall wear an identification badge which shall provide details of his/her name and which identifies the Employment Agency and which features a contemporary photograph of the Temporary Worker.
The Temporary Worker recognises the Employment Business’ obligations under the Conduct of Employment Agencies and Employment Business Regulations 2003 (the Regulations) and hereby agrees to the disclosure of personal information about the Temporary Worker as required in order for the Employment Business to comply with the Regulations.

The Temporary Worker agrees that Employment Business may, if requested, send their personal details to the Client without first informing or requesting their permission.
The Temporary Worker undertakes that they shall not enter into any agreement, whether directly or indirectly, to supply services of a similar nature to the Client or a subsidiary of the Client, other than through the Employment Business for a period of 6 months following the termination of the Agreement
Confidentiality.

Blizz Care believe the value of shared information, but only between those who need to know. This will normally be Blizz Care team members, Other colleagues on the team and other professionals e.g. Doctors or Nurse. It can be degrading to any individual to have intimate and personal details of their care discussed with others. It can also be detrimental to their personal security of people who may try to take advantage of the situation know details of their personal circumstances.

Do not discus care homes, service users or client in online forums, websites, social media or in real.
Conduct expected of Blizz Care Staff.

Blizz Care expect its staff to maintain a good professional caring behaviour at all time when working with client, colleagues and any people with whom you may come into contact. Bullying or any other form of bad behaviour will not be accepted

Refrain from using bad language and any other offensive or insulting behaviour. Proven incidents of sexual, verbal or racial harassment of fellow workers or client, or work place bullying, will result in disciplinary action. You most also comply with policy on the consumption of alcohol, mind altering drugs and smoking on duty.

Complaints and compliments are the basic needs that the client has of expressing satisfaction or dissatisfaction with our service. As the person who is in direct contact with the client you are likely to be the one that the client first contact.
Conduct expected of Blizz Care Staff.

Blizz Care expect its staff to maintain a good professional caring behaviour at all time when working with client, colleagues and any people with whom you may come into contact. Bullying or any other form of bad behaviour will not be accepted

Refrain from using bad language and any other offensive or insulting behaviour. Proven incidents of sexual, verbal or racial harassment of fellow workers or client, or work place bullying, will result in disciplinary action. You most also comply with policy on the consumption of alcohol, mind altering drugs and smoking on duty.

Complaints and compliments are the basic needs that the client has of expressing satisfaction or dissatisfaction with our service. As the person who is in direct contact with the client you are likely to be the one that the client first contact.
Governing law and Jurisdiction

These Terms are governed by the law of England & Wales and are subject to the exclusive jurisdiction of the Courts of England & Wales.

To certify that you have read and understood the contents of the staff handbook and terms of engagement please print and sign below.
Name
N/A

First Name Last Name
Signature
N/A

E-Signature Field
Clear
Date
N/A

dd-MMM-yyyy

Method of payment and Bank Details confirmation
Name
N/A

-Select-

Title First Name Last Name
Bank Name
N/A
Date of birth
N/A

dd-MMM-yyyy
Bank Account
N/A
Sort Code
N/A
NI
N/A
Agency name will not take responsibility of any incorrect bank details provided, please ensure you provide yourbank details correctly.

I can confirm that the information provided above is true, and that the bank details are correct.
Name
N/A

First Name Last Name
Signature
N/A

E-Signature Field
Clear

UKHCA Disclosure Application Form
You can reduce errors and speed up your application process saving you time and money by completeing this application online.

See www.ukhca.co.uk/disclosure/getonlineaccess.aspx to get started.

Please complete the form as full as possible as omissions may cause delays in the processing of the application.

A full 5 year address history must be provided with no gaps in the dates.

All details provided on the form will be sent electronically to the Criminal Records Bureau for processing.
Organisation *
N/A
Job Role *
N/A
Name
N/A

Required
-Select-

Title First Name Last Name
Date of birth *
N/A

dd-MMM-yyyy
Gender *
N/A
Address
N/A

Required Street Address Address Line 2 City State/Region/Province Postal / Zip Code

-Select-

Country
Resident from
N/A
Telephone *
N/A
Surname at birth
N/A
Used untill
N/A
Town of birth *
N/A
County of birth *
N/A
Nationality at birth *
N/A
All other addresses used in the last 5 years
-- No Fields Available --
- Address
- Resident From (MM | YYYY)
- Resident To (MM | YYYY)
Add Entry Add Entry
- Address
  N/A
  
  Required Street Address Address Line 2 City State/Region/Province Postal / Zip Code
  
  Country
- Resident From (MM | YYYY)
  N/A
  
  dd-MMM-yyyy
- Resident To (MM | YYYY)
  N/A
  
  dd-MMM-yyyy
- Address
  N/A
  
  Required Street Address Address Line 2 City State/Region/Province Postal / Zip Code
  
  -Select-
  
  Country
- Resident From (MM | YYYY)
  N/A
  
  dd-MMM-yyyy
- Resident To (MM | YYYY)
  N/A
  
  dd-MMM-yyyy
Passport Number *
N/A
Issue Date *
N/A

dd-MMM-yyyy
Nationality
N/A
Issue Country
N/A
Expiry Date
N/A

dd-MMM-yyyy

All other identity documents seen

	Yes/No
Biometric Residence Permit (UK) *	-Select-
Letter of Sponsorship from future employment provider (Non-UK/Non-EEA only - valid only for those residing outside of the UK at time of application *	-Select-
P45/P60 Statement (less than 12 months old) (UK & Channel Islands) *	-Select-
Bank/Building Society Statement (UK or EEA) (less than 3 months old) *	-Select-
Mortgage Statement (UK or EEA) (less than 12 months old) *	-Select-
Credit Card Statement (UK or EEA) (less than 3 months old) *	-Select-
Financial Statement (less than 12 months old) - e.g. pension, endowment, ISA (UK) *	-Select-
Work Permit/Visa (UK) (UK Residence Permit) (valid up to expiry date) *	-Select-
Council Tax Statement (UK & Channel Islands) (less than 12 months old) *	-Select-
Benefit Statement (less than 3 months old) - e.g. Child Allowance, Pension *	-Select-
Bank/Building Society Account Opening Confirmation Letter (UK) (less than 3 months old) *	-Select-
Land line Telephone Bill (NOT a mobile phone bill) (UK) (less than 3 months old) *	-Select-
Electricity Bill (UK) (less than 3 months old) *	-Select-
Gas Bill (UK) (less than 3 months old) *	-Select-
EU National ID Card *	-Select-
A document from Central/Local Government/ Government Agency/Local Authority giving entitlement (UK & Channel Islands) (less than 3 months old) *	-Select-
Letter of Sponsorship from future employment provider (Non-UK/Non-EEA only - valid only for applicants from outside of the UK at time of application *	-Select-

- If you have seen 1 or more Group 1 document and seen at least 2 other documents (including a document that verifies address) external validation will not be required.
  
  You must have seen at least 1 Group 2a document and at least 2 other documents (including adocument that verifies address) to qualify for external validation. Otherwise we will be unable to process the application. Further information is available at www.ukhca.co.uk/disclosure/identity.aspx
National Insurance Number
N/A
Mother’s Maiden Name
N/A

FOR COMPLETION BY EMPLOYER

	Yes/No
Will the applicant be working with vulnerable adults? *	-Select-
Will the applicant be working with children? *	-Select-
Would you like to perform an ISA Adult First check on the applicant? *	-Select-
Does the applicant’s identity need to be externally verified? *	-Select-
Will the applicant be employed as a volunteer? *	-Select-

Disclosure Type
N/A

-Select-
Preliminary Verifier
N/A
- I confirm that the I have established the true identity of the applicant, by examining a range of documents as set out in CRB guidance and verified the information provided by the applicant as it has been entered.
Preliminary Verifier Signature
N/A

E-Signature Field
Clear
Date
N/A

dd-MMM-yyyy
- Declaration by the applicant
Have you ever been convicted of a criminal offence or received a caution, reprimand or warning?
N/A
- I confirm that the information that I have provided in support of this application is complete and true and understand that knowingly to make a false statement for this purpose is a criminal offence.
Applicant’s Signature
N/A

E-Signature Field
Clear
Date
N/A

dd-MMM-yyyy
- Once this form is completed in it’s entirity you should return it with payment to UKHCA Disclosure Service
  
  Sutton Business Centre
  
  Restmore Way
  
  Wallington
  
  SM6 7AH
  
  Details of our current prices can be found at www.ukhca.co.uk/disclosure/crbcosts.aspx
  
  You can reduce errors and speed up your application process saving you time and money by completeing this application online. See www.ukhca.co.uk/disclosure/getonlineaccess.aspx to get started.
Sub form
N/A

Application Form

To join our team, kindly fill out the application form below

Application Form

Rehabilitation of Offenders Act 1974

Working Time Regulation

GDPR

BLIZZ CARE - TERMS OF ENGAGEMENT

3. ASSIGNMENTS

4. FEES AND CHARGES

7. TERMINATION

8. SPECIAL PROVISIONS

Confidentiality.

Method of payment and Bank Details confirmation

UKHCA Disclosure Application Form

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