RCB Healthcare Application Form

Page 1: Introduction and Personal Information

Our organisation is committed to safeguarding and promoting the welfare of adults at risk and/or children and expects all our staff and volunteers to share these values.

We are also committed to treating all applicants equally and fairly based on their skills, experience, and ability to fulfil the duties required of the role applied for. This is regardless of any protected characteristics (ethnicity, gender or gender reassignment, religion or belief, sexual orientation, physical/mental disability, age, pregnancy or maternity, marriage, or civil partnership).

Applicants must share with us all the relevant information that we have requested in this application form, but we would like to reassure applicants that any information provided will be treated in the strictest confidence in a fair and open manner. Suitable applicants will not be refused employment because of offences or conduct which are no longer relevant, and do not place them at, or make them a risk in – the role for which they are applying.

We will ensure that all our recruitment and selection practices reflect this commitment.

Page 2: Post Details

1. Post applied for location

This field is required.

2. On what position are you applying for?

This field is required.

3. How did you hear about this position?

This field is required.

4. How many hours you looking for?

This field is required.

5. Name

First Name

This field is required.

Middle Name

Last Name

This field is required.

6. Email

Please enter a valid email address with @.

7. Phone number

Please enter a valid UK mobile number (exactly 11 digits).

8. NIN - NATIONAL INSURANCE NUMBER Insert maximum 9 characters.

Must contain 9 Characters (letters and numbers only, no special characters).

9. Address

All required address fields must be filled.

10. Are you a relative or a partner of, or do you have a close personal relationship with any employee of RCB Healthcare?

This field is required.

11. Have you previously been employed or sought employment with RCB Healthcare?

This field is required.

Page 3: Right to Work

1. Do you or will you in the future require sponsorship?

Yes No

This field is required.

2. Have you been granted a visa to work in the UK?

Yes No Not applicable

⚠️ Please select one option

3. Do you have any restrictions on your working hours?

Yes No

This field is required.

4. Which of the following do you have to prove your right to work in the UK?

British Birth Certificate UK / Irish Passport Share Code

This field is required.

5. Please attach Right To Work, Document or Image. (Allowed: PDF, DOCX, PNG, JPEG, JPG, GIF, BMP, WEBP, TIFF, HEIC)

Please upload valid documents.

Page 4: Professional registration (if applicable)

Row	Professional body (if applicable)	Registration / Membership Level	Date awarded	Action
1

Page 5: Other relevant training or qualifications

Row	Course / Training Name	Date of Certificate or Diploma	Action
1

Page 6: Education History

Please include all periods of education, in chronological order starting from secondary school, with full dates of starting and leaving. Include any gaps in education (if any) between the various stages.

1. Date of Birth

Date of Birth is required to verify your education and employment history.

Your date of birth is needed to check for any gaps in your education and employment timeline.

2. Did you attend secondary / high school? (Usually between the ages of 11 and 16 years old)

Yes No

This field is required.

3. Did you attend college / sixth form? (Usually between the ages of 16 and 20 years old)

Yes No

This field is required.

4. Did you attend university?

Yes No

This field is required.

Work History

Please provide full employment history with full start and end dates, in chronological order, starting from your first job after leaving secondary education. Include part-time and voluntary work as well as full time employment.

Please detail ALL periods when you were not in employment or education. If the gap is more than four weeks, can you provide supporting evidence? If not, please explain why. Examples of supporting evidence are:

A reference from a person of standing. The individual is referred to as a gap referee.
Travel documents to evidence periods of travel
Job centre letter or other evidence of claiming benefits for periods of unemployment.

IMPORTANT NOTE: When providing reason for leaving, for each role, please confirm that you were not under investigation for or subject to any Disciplinary sanctions in relation to your conduct at the time of leaving/dismissal. If you were, please provide details.

Employer Name and Address (1)

Employer name is required.

Start Date (1)

This field is required.

End Date (1)

This field is required.

Post held and Duties (1)

This field is required.

Reason for leaving (1)

This field is required.

Page 7: References

Please provide contact details for two most recent referees who are able to comment on your suitability for the job applied for. You are responsible for providing accurate contact details so that referees can be contacted.

The first referee MUST be your current or most recent employer (or your course tutor if you are currently in, or have just left, full time education).
Professional references will not be accepted from work colleagues who are not authorised to provide professional references in an official capacity on behalf of the organisation, or from people writing solely in the capacity of friends, or from relatives.

1. Can we approach your referees before an offer of employment?

Yes No

⚠️ Please select one option

Referee 1 (Current/Most Recent Employer)

Referee 2

Important Information:

Our organisation will seek references on successful candidates, and will approach previous employers for information to verify particular experience or qualifications. If you are currently working with adults at risk and/children, your current employer will be asked about disciplinary offences relating to adults at risk and/children (including any conduct related to safeguarding concerns which the penalty is 'time expired'), and whether you have been the subject of any safeguarding related investigations or concerns, and if so, the outcome of any enquiry or disciplinary procedure including any referrals to Disclosure and Barring Service (DBS), other professional bodies or the police.

Any previous employment involving vulnerable adults and/children will also be approached to provide references and verification of employment dates. If you are successful at interview, any offer of employment will be subject to receipt of two satisfactory references and any additional pre-employment check.

Page 8: Equal Opportunities

RCB Healthcare Group is committed to a policy of equal opportunities for all applicants and employees and will not discriminate against anyone on the grounds of race, gender, sexual orientation, disability, age, religion or any other personal characteristic.

Please complete the equal opportunities form available separately. This information will not be used as part of the selection process and will be treated in the strictest confidence.

Page 9: Criminal Record Checks

RCB will only ask those candidates who have been selected for interview to complete a criminal record self-declaration form or provide a written disclosure statement to give them the opportunity to provide sufficient information.

At interview, or in a separate confidential discussion, we will ensure that an open and measured discussion takes place on the subject of any offences that might be relevant to the position.

We will only carry out criminal record checks with DBS on successful candidates at the appropriate level for the role applied for.

Failure to provide accurate and truthful information is considered a serious matter.

If it becomes apparent that inaccurate or incomplete information has been provided, we will need to establish why.

Any finding of serious misdirection or intent to deceive will result in an application being disqualified or, if appointed, disciplinary action may be taken up to and including dismissal.

Page 10: Conduct declaration

1. Have you ever been subject to any sanctions being placed on your professional registration, by a regulatory or licensing body in any country? Sanctions may include: Warnings, conditions, limitations, suspension, removal or any other restrictions that have applied to your professional registration.

This field is required.

2. Have you ever been under investigation for or subject to any disciplinary sanctions in relation to your conduct at the time of your dismissal/leaving any employment, volunteering, office, or other position previously held by you?

This field is required.

Page 11: DBS barred lists

This post involves working in Regulated Activity under the Safeguarding Vulnerable Groups Act 2006 and is subject to an enhanced DBS with barred list check (i.e. adults, children or both). It is a criminal offence to apply for or accept a position working with adults at risk and/or children if you have been barred from engaging in regulated activity with the relevant group (i.e. adults, children or both).

1. Are you included in the list of people barred from working with adults maintained by the Disclosure and Barring Service (DBS) under the Safeguarding Vulnerable Groups Act 2006?

This field is required.

2. Are you included in the list of people barred from working with children maintained by the Disclosure and Barring Service (DBS) under the Safeguarding Vulnerable Groups Act 2006?

This field is required.

3. If you are not currently barred from working with adults at risk and/or children under the Safeguarding Vulnerable Groups Act 2006, have you been referred to the Disclosure and Barring Service (DBS) for consideration to be added to one of the barred lists?

This field is required.

4. Have you ever been under investigation for or subject to any disciplinary sanctions in relation to your conduct at the time of your dismissal/leaving any employment, volunteering, office, or other position previously held by you?

This field is required.

Page 12: Declaration

I declare that the information I have given in this application is correct and complete. I understand that any false statements or failure to disclose information requested on this form may result in my application being disqualified or may lead to my dismissal or disciplinary action if appointed. I understand that if I am appointed, personal information about me may be stored for personnel/employee administrative purposes in accordance with relevant Data Protection legislation, including UKGDPR/DPA 2018 and any other UK legislation which supports it. Our organisation will process the data you give us to determine your suitability for the role you have applied for as part of the recruitment process and the ongoing employment relationship if appointed. In submitting this form, I give my authority for use of my personal data for the purposes outlined above.

I agree

This field is required.

Page 13: Data Storage Information

All information on this form will be treated in strictest confidence and used to process your application for employment. If you are appointed, this application will form the basis of your personal file and information on this may be held in an electronic database. If your application is unsuccessful your details will be kept for a period of 12 months and then destroyed.

I agree

This field is required.

Page 14: DBS (Disclosure and Barring)

Along with details you have already provided in this application, this additional information is required in order for the Company to carry out a DBS check request.

This process verifies your criminal record history to confirm your suitability for roles involving vulnerable individuals. Please provide accurate details to facilitate this check; any discrepancies may delay your application.

Important: Since birth, please provide all the names you have been known by - i.e. from birth, whether married previously, adopted, etc. This would apply to surnames and forenames.

Position applied for:

This field is required.

NIN - NATIONAL INSURANCE NUMBER: Insert maximum 9 characters.

Must contain 9 Characters (letters and numbers only, no special characters).

1. Gender:

This field is required.

Title:

This field is required.

Date of Birth:

This field is required.

Place of Birth (City & Country):

This field is required.

First Name:

This field is required.

Middle Name(s):

Surname:

This field is required.

2. Have you ever changed your name?

Yes No

This field is required.

2a. If YES, please provide more details below:

Name 1

Previous Names	Surnames	Used From	Used To

3. Do you have a dual nationality

Yes No

This field is required.

3a. If Yes, please provide more details below:

Nationality at Birth (as per passport)	Current Nationality (as per passport)

This field is required.

4. Do you have any convictions, cautions, reprimands or final warnings?

Yes No

This field is required.

5. Please provide your current address

📅 Required period: Loading...

Please provide addresses covering the last 5 years from today's date.

Current Address details	Move-in date	Move-out date / Present
		Present

Current address and move-in date are required.

6. Previous Addresses (Last 5 Years)

Important: If you have lived at any other addresses in the last 5 years, please add them below.
The timeline will detect any gaps - all gaps must be explained before proceeding.

Row	Street Address	City	Postcode	Move-in date	Move-out date / Present	Action
1					Present

Page 15: GDPR (2018) - DBS Applicant Consent

Privacy Policy - Standard/Enhanced Checks declaration.
I have read the Standard/Enhanced Check Privacy Policy for submitting an application.

Consent to obtain e-Bulk standard/enhanced check electronic result.
I consent to the DBS providing an electronic result directly to the registered body that has submitted my application.

Consent to my application.
I understand that an e-Bulk standard/enhanced check electronic result contains a message that indicates either the certificate is blank or to await certificate which will indicate that my certificate contains information. In some cases the registered body may provide this information directly to my employer prior to me receiving my certificate.

Declaration by Applicant.
I confirm that I have provided complete and true information in support of this application and understand that knowingly making a false statement for this purpose is a criminal offence.

I agree

This field is required.

Page 16: Criminal Record Self-declaration form for jobs exempt from the Rehabilitation of Offenders Act (ROA) 1974

This form must be completed by all applicants for jobs, activities or posts that are eligible for standard or enhanced DBS checks. The information disclosed on this form will not be kept with your application during the selection process and therefore applicants are required to declare all unspent cautions and convictions, and also any adult cautions or spent convictions that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020.

For further information on criminal record self-declaration for roles that are eligible for standard or enhanced DBS checks please refer to Nacro guidance Moj guidance and/or DBS guidance.

We recognize the contribution that people with convictions can make as employees and volunteers and welcome applications from them. A person's criminal record will not in itself, prevent a person from being appointed to this post. Any information given will be treated in the strictest confidence. Suitable applicants will not be refused posts because of offences which are not relevant to, and do not place them at or make them a risk in, the role for which they are applying.

All cases will be examined on an individual basis and will take the following into consideration:

Whether the caution or conviction is relevant to the position applied for
the seriousness of any offence revealed
the age of the applicant at the time of the offence(s)
the length of time since the offence(s) occurred
whether the applicant has a pattern of offending behaviour
the circumstances surrounding the offence(s), and the explanation(s) offered by the person concerned
If the applicant's circumstances have changed since the offending behaviour.

It is important that applicants understand that failure to disclose all unspent cautions and convictions, and also, any adult cautions and spent convictions that are not protected - regardless of whether they're convicted in the UK or abroad; and/or relevant service discipline convictions received within the Service Justice System (e.g., through Summary Hearing or Court Martial) - could result in disciplinary proceedings or dismissal.

You can use the self-disclosure rules flowchart to work out which offences you may need to disclose.

Page 17: Criminal record self - declaration form ROA Exceptions Order (standard or enhanced DBS checks)

Name

First Name

This field is required.

Middle Name

This field is required.

Last Name

This field is required.

1. Do you have unspent cautions or convictions under the Rehabilitation of Offenders Act 1974?

Yes No

This field is required.

If you have answered yes, you now have two options on how to disclose your criminal record.

Option A
Please provide details of your criminal record in the space below:

Option B
You can disclose your record in a written statement provided that you tick the box below and attach the disclosure statement stapled to this form in an envelope. The envelope should be marked CONFIDENTIAL and state your name and the details of the post you are applying for. I have attached details of my criminal record separately Attach Document: Declaration I declare that the information provided on/with this form is correct. I understand that the declaration of a criminal record will not necessarily prevent me from being offered this role at RCB Healthcare Group. Signature: Date:

Option B

You can disclose your record in a written statement provided that you tick the box below and attach the disclosure statement stapled to this form in an envelope. The envelope should be marked CONFIDENTIAL and state your name and the details of the post you are applying for.

I have attached details of my criminal record separately

Attach Document:

Declaration

I declare that the information provided on/with this form is correct. I understand that the declaration of a criminal record will not necessarily prevent me from being offered this role at RCB Healthcare Group.

Signature:

Date:

2. Do you have any adult cautions or spent convictions that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020?

Yes No

This field is required.

If you have answered yes, you now have two options on how to disclose your criminal record.

Option A
Please provide details of your criminal record in the space below:

Option B
You can disclose your record in a written statement provided that you tick the box below and attach the disclosure statement stapled to this form in an envelope. The envelope should be marked CONFIDENTIAL and state your name and the details of the post you are applying for. I have attached details of my criminal record separately Attach Document: Declaration I declare that the information provided on/with this form is correct. I understand that the declaration of a criminal record will not necessarily prevent me from being offered this role at RCB Healthcare Group. Signature: Date:

Option B

You can disclose your record in a written statement provided that you tick the box below and attach the disclosure statement stapled to this form in an envelope. The envelope should be marked CONFIDENTIAL and state your name and the details of the post you are applying for.

I have attached details of my criminal record separately

Attach Document:

Declaration

I declare that the information provided on/with this form is correct. I understand that the declaration of a criminal record will not necessarily prevent me from being offered this role at RCB Healthcare Group.

Signature:

Date:

Date of Submission

Signature

Page 18: Submission Confirmation

Your application has been submitted. Thank you! We will contact you.

RCB Healthcare Application Form

⚠️ Timeline Gaps Detected - Explanation Required

Name 1

⚠️ Name Timeline Gaps Detected

Address Timeline Gaps Detected