This ‘online Application’ is presently in Beta testing and as such may not function as expected. ┬áIf you experience any problems please download the full application pack and submit in the normal way.

Pre-application form.

This pre-application form must be completed in full. Once completed and submitted you will be contacted by a member of our HR team within 3 working days.

Post being applied for (required)

Other - Please Specify

Your Title (required)

Your Name (required)

Where is the post located (required)

Other - Please Specify

Your Date of Birth (required)

Your Email (required)

Previous Names Used

Date From

Your Address (including postcode)

Date To

Your Home Telephone Number (required)

Your Mobile Telephone Number

Your Work Telephone Number (optional)

Present or Latest Employment

If you have more than one post please provide details of the most relevant post here and include your other post/s under previous employment.

Present Post Title

Name and Address of Workplace

Salary, Point and and Additional points or allowances

Date From

Date To

Period of Notice

Key Duties and Responsibilities

Previous Post Title

Name and Address of Workplace

Salary, Point and and Additional points or allowances

Date From

Date To

Key Duties and Responsibilities

Previous Post Title

Name and Address of Workplace

Salary, Point and and Additional points or allowances

Date From

Date To

Key Duties and Responsibilities

Driving Licence

Do you hold a current full driving licence for the UK? (You will be required to produce this documentation at interview) Yes No

Do you have a current class C1 category / capability on your licence? Yes No

Do you have a current IHCD D1/D2 class blue light driving qualification? Yes No

Do you have an emergency driving qualification other than IHCD D1/D2  Yes No

If Yes, please specify

Do you have any points or convictions on your licence? (It is our policy to refer to our customer those with more than 3 points and exclude those with 6 or more)  None 3 Points or less 4 - 5 Points 6 Points or more Other convictions (specify below)

Please detail your Driving Licence number (including the last 2 digits on your photo driving licence if you have one)

How long have you held a driving Licence?

What experience have you had driving larger vehicles?

NHS Staff

Are you a Healthcare professional? (either practicing or returning to practice) Yes No Returning to practice

Which professional body are you registered with?

Are you currently the subject of a fitness to practice investigation or proceedings by a licensing or regulatory body in the UK or any other country (if yes provide details in the space provided below) Yes No

Have you been removed from a register or have conditions been made on your registration by a fitness to practice committee or the licencing or regulatory body in the UK or any other country? (if yes provide details in the space provided below) Yes No

Have you ever been asked to leave employment from any employer or NHS Trust? (if yes provide details in the space provided below) Yes No

Asylum and Immigration Act, 1996
Can you provide evidence of your legal right to work in the UK? (You will be required to produce this documentation at interview) Yes No

Equality and Diversity Monitoring

Human Touch Ambulance Ltd welcomes applications from disabled people.

We are committed to interviewing all disabled applicants who meet the minimum criteria of the role applied for. Please indicate below if you consider yourself to have a disability*. In addition please advise us of any reasonable adjustments which are needed to ensure the interview is accessible to you.

*For this purpose, disability is defined as any physical or mental impairment which has substantial and long term adverse effect on your ability to carry out normal day to day activities. Long term means the effect of the impairment has lasted at least 12 months, is likely to last for 12 months, or is likely to last for the rest of the persons life.

Do you consider yourself to have a disability? Yes No Prefer not to disclose

Do you require any reasonable adjustments in relation to your interview? Yes No

If yes, please give details

Are you, to the best of your knowledge, related to any person employed or previously employed by Human Touch Health Group? Yes No

If yes, please give details

Criminal Convictions - Rehabilitation of Offenders Act 1974

All staff in patient facing and selected other roles will be required to complete an Enhanced DBS check.

Do you have a Portable Enhanced DBS check? Yes No

Failure to disclose any information required of you may result in your application being rejected, or if discovered at a later date may lead to disciplinary action or dismissal.

Do you have an criminal record information to disclose? Yes No

If yes, please give details

Declaration

1. By pressing the send button I declare that the information given on this form is true and accurate to the best of my knowledge.

2. By pressing the send button I declare that I understand all the questions on this form.

3. By pressing the send button I understand that deliberate omissions and incorrect statements could lead to my application being rejected or to my dismissal if appointed to the post.

4. By pressing the send button I understand that evidence of my qualifications will be required during the selection interview process.

5. By Pressing the send button I understand that satisfactory references, Enhanced DBS disclosure, medical clearance and evidence of the wright to work in the UK will be required before any final offer of employment can be made.

Electronic signature (required)

Date

All information provided on this form will be dealt with in accordance with the Data protection Act 1984, amended 1998. This information may be computerised and used for administration purposes within Human Touch Health Group Ltd. All personal information computerised by the company has to be registered and may only be used and disclosed as described in the Data Protection Register.