Job Application Form

MEGA Health Services

Job Application
Position Applying For
Personal Particulars
Prefix*

Mr.MsMrs.Miss
Full Names*

First NameMiddle NameLast Name
Marital Status*

SingleMarriedDivorcedWidowed
Date Of Birth*

DayMonthYear
Date
Country Of Birth*
Nationality*
National Insurance Number*
Upload Your Driving License, Identity Card,Passport, Proof of address, & Supporting documents

Cancelof
Bank Details
Bank Name
Address

Street Address

CityState / Province

Postal / Zip Code
Sort Code
Account Number
All details are held in the strictest confidence under the Data Protection Act 1998. I authorise Mega Health Services to make payments to this account for work done*

I Agree
Date

MonthDayYear
Date

Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Tel. No.
Mobile Tel. No.*
Email*
example@example.com
Fax No.
Correspondence Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Educational Qualifications
Professional Qualifications
Name and Address of Employer and Nature of Business:
Dates To and From employed
Job Title: job Functions/Responsibilities
Final Salary and Reason for Leaving

Proficiency In Languages
Native Language
Second Language (optional)
Proficiency In Speaking Second Language
Proficiency In Writing Second Language
Proficiency In Reading Second Language
Third Language (optional)
Proficiency In Speaking Third Language
Proficiency In Writing Third Language
Proficiency In Reading Third Language
Do You Hold a Full Uk Driving License Or Equivalent

YesNo
Details Of Any Endorsement
Do You Have A Car?

YesNo

References
Name of references
Address Of References
Position Of Reference
Telephone/Fax No of Reference
Type a question

Medical History

Please complete the following questions by ticking the appropriate box. If the answer is ‘yes’, give details including (a) date, (b) amount of time lost from work/school, (c) treatment, as appropriate.
Have you ever suffered from any of the following illnesses?
Visual defects/eye conditions (including colour-blindness)

YesNo
If yes please provide details
Hearing defects/ear conditions

YesNo
If yes please provide details
Severe anxiety, depression, other psychiatric disorder

YesNo
If yes please provide details
Paralysis or other neurological disorder

YesNo
If yes please provide details

PRESENT HEALTH STATUS
Had a chest X-ray in the past 12 months – If so state place / date / result

YesNo

Interview Questionnaire
Full Names*

First NameLast Name
Position Applied For
What are your strengths?
What are your weaknesses?
What are your goals?
What makes you a good candidate for this job?
If you encountered a service user who was upset what would you do?
If you encountered a service user who was being aggressive towards you or another resident how would you deal with it?
How would you transfer a resident from a bed to a wheelchair?
What is a care plan? Why should it be kept up-to-date?
What is the purpose of a hand-over?

Describe what you would do if a service user were to have an accident? Who would you report this to?
What does 'Promoting Independence' means?
How would you promote infection control?
What items do you use to prevent the spread of infection?
How would you dispose of clinical waste?
What would you do if you witnessed another employee stealing?
What would you do if witnessed another employee being aggressive with a service user?
What would you do if you witnessed another employee not abiding by health, safety and infection control policies?
What would you do if you were uncertain of what to do on a shift?
What would you do if you did not understand or felt you didn't have enough training in certain areas of mandatory expectations?
You confirm that everything completed in this section is correct and attest to your character?*

Yes, I agree
Date*

MonthDayYear
Date

Terms Of Engagement

Contract For Services
Thank you for applying to Mega Health Services. These terms & conditions ("Terms and Conditions") apply to the Site and its application service which reference these Terms and Conditions. Kindly review the Terms and Conditions listed below diligently prior to submitting this form as your submission on this website indicates your agreement to be wholly bound by its Terms and Conditions without modification. You agree that if you are unsure of the meaning of any part of these Terms and Conditions or have any questions regarding the Terms and Conditions, you will not hesitate to contact us for clarification. Click here to review.
Temporary Worker's Full Names*

First NameLast Name
You acknowledge that you have read and agreed to the terms and conditions of the contract attached herewith?*

Yes, I agree
Date*

MonthDayYear
Date

Declaration

I certify that all entries are true and correct. I understand that all information on this application is subject to verification. I agree and understand that, in the event of my employment by Mega Health Services, Inc, I shall be subject to dismissal if any information that I have given in this application is false or misleading, regardless of time of discovery. I undertake to notify Mega Health Services, Inc of any changes in my circumstances, including health, criminal convictions and driving license endorsement, which would or could affect my ability to work. I understand that Mega Health Services, Inc may release my personal details to a client in order to secure work or to enable the client to verify my identity or eligibility to work. These details may include name, age, driving license, work history, criminal record, health questionnaire and proof of identity or eligibility to work. I authorize the Mega Health Services, Inc to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I hereby acknowledge that I have read and agree to the above statements
Date*

MonthDayYear
Date
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