RN Registration Position applied for *Date of Application *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Who referred you to Legit Care Recruitment? * PERSONAL DETAILS  TitleFirst Name *Middle NameLast NameStreet AddressCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweMobile Number *Landline PhoneDate Of Birth *Gender *MaleFemaleEmail Address * RELATED INFORMATION  Present or Last EmployerJob TitleAddress of EmployerDates Of Employment From - To (dd/mm/yy)Duties (To include last 5 years)  Name of EmployerJob Title & DutiesStart Date - End Date (dd/mm/yy)DISCLOSURE & BARRING SERVICE (DBS) *Please note you will be subject to an enhanced DBS check. Because you are a healthcare worker, you are not exempt from the Rehabilitation of Offenders Act 2010. This means that all convictions, cautions, reprimands and final warnings on your criminal record MUST be disclosed.*  Are you signed up to the dbs update service? {Where you have registered your dbs number online and paid £13.00 annual subscription fee) *YesHave you ever been convicted by the courts, cautioned,reprimanded or given a warning by the police in the UK or in any other country? *YesNoAre you aware of any Police enquiries undertaken following allegations made against you, which may affect your suitability for this role? *YesNoAre you aware of any pending investigations by the police in which you are involved? *YesNoIf you have answered Yes to any of the above questions please provide full details on the incident below:N.B. Any information disclosed will be taken into consideration but will not automatically prevent your application from proceeding. However, if you are appointed, failure to disclose any criminal conviction could lead to termination of our ability to act as your agent. NEXT OF KIN NameRelationshipPhone/Mobile REFERENCES Please give details of two previous employers, one of which should be your previous employer. REF 1: Contact Name *Name of Previous Employer *Address *Phone *Job Title *Email *REF 2:Name of Previous Employer *Contact Name *Address *Job Title *Phone *Email *Do you consent to Legit Care Recruitment contacting your references? *YesNoASSOCIATE SKILL PROFILE Please select a list of client groups and illnesses you have experience working with.ELDERLYEMIAcquired brain injuryAlzheimer’s DiseaseDementiaMental illnessChronic physical conditions such as multiple sclerosis and Huntington’s diseaseKorsakoffs diseasePersonality DisordersCerebral palsyPalliative careParkinson’s diseaseEpilepsyPressure soresMENTAL HEALTHYoung peopleBereavementForensicAnorexia and bulimiaAlcohol AbuseObsessive Compulsive disorderAnxiety, panic and phobiasDepressionPersonality disorderBipolar disorderSchizophreniaDrugsSubstance misusePhysical illnessPostnatal mental healthPost-traumatic stressENVIROMENTResidentialSecure unitHostelsRehab centreSheltered AccommodationPrisonHomelessnessDomestic Violence/refuge For womanDrop in centreWet HostelsSupported LivingHospitalNursing HomeLEARNING DISABILITYAdult Asperger syndromePrader-willie SyndromeAutism & Asperger syndromeAttachment disorderFragileTourette’s SystemDown syndromeWilliams syndromeEpilepsySemantic pragmatic disorderCelebral palsyADHDDyspraxiaRett syndromeDowns syndromePDA (pathologigical demand avoidance)EUROPEAN WORKING TIME DIRECTIVE *Yes, I may wish to work more than 48 hours per week.No, I do not wish to work more than 48 hours per week.Working HoursDECLARATION *I confirm that the information set in this form is true and correct, is not misleading and that no material information has been omitted. I understand and agree that if I submit any false or misleading information, this may result in any offer or registration with the Agency being withdrawn, or if already accepted to the agency, in my dismissal.I hereby authorise Legit Care Recruitment to secure all information it may require in connection with my application for registration, subject to any specific direction I have made related to contacting my referees.I confirm that I have read and understood the Terms and Conditions of Engagement offered by Legit Care Recruitment and agree to be bound by and comply with the sameI have no objection to my details being held on computer records and utilised by the company in pursuit of its legitimate business.I understand that my application is subject to the receipt of satisfactory references, police clearance, (Criminal Records Bureau, CRB Disclosure) and any other checks (where appropriate).I agree to inform Legit Care Recruitment of any Changes or additions to the information I have supplied.I consent to my profile being accessed for the purposes of an audit by any external firm auditing Legit Care RecruitmentCONFIDENTIALITY AGREEMENT *To hold information relating to the client in the strictest confidence, ensure it is kept safely and securely when not in use. I acknowledge that no information is to be removed from the clients premises without the permission of the clientTo use such information only for the purpose of the work for which it is given.Not to disclose to any third party or copy the information except as is required in the course of my duties *Any breach, either by myself or a third party, may result in legal proceedings being brought by the client against me to recover any loses that have occured as a result of a breach.PLEASE SELECT YOUR TAX STATUS: *P.A.Y.ELIMITED CONTRACTORPassport Front Cover *Choose FileNo file chosenDelete uploaded fileClick or drag a file to this area to upload.The Photo Page(s) *Choose FileNo file chosenDelete uploaded fileClick or drag a file to this area to upload.A page showing the passport number *Choose FileNo file chosenDelete uploaded fileClick or drag a file to this area to upload.Any pages showing relevant and valid visas (if appropriate) *Choose FileNo file chosenDelete uploaded fileClick or drag a file to this area to upload.Date *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925GDPR Agreement * I consent to having this website store my submitted information so they can respond to my inquiry. 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