DHS Application Pack New

APPLICATION
Dohatech Health Services

14 Alamein Road,
PACK COLCHESTER, Essex,
CO2 9LG EXPERIENCE OUR COMMITMENT TO EXCELLENCE
APPLICATION PACK
EXPERIENCE OUR COMMITMENT TO EXCELLENCE
Dear: Prospective Candidate
Please find enclosed an application pack for completion. This application pack must be completed and
returned by post or bring it in person at the above address.
Please note: you can attach your CV to cover your Education and Work experience.
INTERVIEWS
When invited for your interview, you will need to produce your original passport, national insurance card/
P60/ P45, proof of current address and any other particulars relevant for identification.
Please note: All other pre- employment checks will be undertaken during the interview; hence, you must
make all documents available at interview to avoid any delays in you starting work. If unsure of what to
bring, please email info@dohatechealthservice.co.uk or call the office on 0800 999 1867.
Wish you all the best in completing this form and be assured it is the first step towards a
rewarding career path.
Email: info@dohatechealthservice.co.uk / dohatechealthservice@gmail.com
Yours Sincerely
Dohatech HealthService
This application pack is made available by Dohatech Health Service Ltd and can be accessed as a hardcopy from our Company office. Policy number DHS/Application
pack. Updated annually and reviewed every six months signed…25.9.20………… 1
APPLICATION
14 Alamein Road,
Application Pack
Please complete all sections using CAPITAL LETTERS
Personal Details
Mr  Mrs  Miss  Ms  Surname:
Forename(s): Any Names Previously Used:
Current Address Contact Details
Home:
Mobile:
Postcode: Email:
Date of Birth: / / Do you Require a Visa to Work in the UK?

Yes  No 
Type:
National Insurance Number:
Expiry Date: / /
NMC Pin Number:
Expiry Date: / /
Do You Hold a Full Driving Licence?
Yes  No 
Do You Have a Current Enhanced DBS? Do You Have Access to a Vehicle for work?
Yes  No  Yes  No 
If Your DBS is Registered with the Online Update Service Please State the Reference Number:
Nationality: Fluent Languages than English?
In the event of an emergency who is the appropriate person we can contact quickly?
Name: Relationship to You:
Home: Mobile:
What Type of Work Are You Seeking? Qualified Nurse  Healthcare Assistant 
Housekeeping/Cleaning  Living in Carer 
Temporary  Permanent 
APPLICATION
14 Alamein Road,
Education History
Please give details of ALL education dating back to secondary school including any college/university/further education.
From To (mm/yy): Name of School/College/University: Course/Qualification:

(mm/yy)
Work History
Please provide details of your work history since leaving school listing your most recent employer first and including
explanations for any gaps in employment. Please complete all information fully as we will seek to obtain references to cover
the last 3 years
From: To: (mm/yy) Company Name & Address: To comply with legislation, if this employment
(mm/yy) was with an employment agency, please list the
companies you have worked at through them.
Please Explain Any Gaps
From: To: Postcode:

(mm/yy) (mm/yy)
Job Title:
Name of Manager:
Reason for Leaving:
Can we contact them before interview? Yes  No 
APPLICATION
14 Alamein Road,
From: To: (mm/yy) Postcode:

(mm/yy)
Job Title:
Name of Manager:
Reason for Leaving:

(mm/yy)
Job Title:
Name of Manager:
Reason for Leaving:

(mm/yy)
Job Title:
APPLICATION
14 Alamein Road,
Name of Manager:
Reason for Leaving:
Additional Training
As part of the registration process you are required to complete all mandatory training courses as well as ongoing care specific
training. If you have completed any mandatory courses within the previous 12 months or any additional care related courses
and can supply copies of certification please provide details.
Course: Date Expiry Date: Organising Body:

Completed:
Working Time Regulations Opt Out Agreement: (completion of this section is optional)
The Working Time Regulations were introduced in 1998 and one of the things they do is limit the average working week to a
maximum of 48 hours. If you wish to work more than 48 hours you can choose to opt-out by signing this section.
I wish to opt-out of the 48-hour working week and agree that The Working Time Regulations 1998 shall not apply to me. My
average working week may therefore exceed 48 hours for each seven-day period.
You may terminate this agreement at any time by giving Dohatech HealthService 14 days written notice.
(Employee) (On behalf of Dohatech HealthService)

Signed: Signed:
Date: / / Date: / /
Rehabilitation of Offenders Act

Due to the nature of work for which you are applying, the provisions of section 4 (2) of the Rehabilitation of Offenders Act
(1974) (Exceptions) order (1975) apply. You are therefore required to declare any cautions or convictions including those
considered “spent” under this Act.
APPLICATION
14 Alamein Road,
Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police
investigation, which might lead to a conviction, an order binding you over or a caution in the UK or any other country?
Yes  No 
If “Yes” please use the sheet overleaf to give further details. This will be removed from your application and stored securely.
Any information given will be completely confidential and will be considered only in relation to the position for which you are
applying.
I understand the terms above and declare that the information given on this form is complete and accurate.
Signed: Date: / /
Please give details of any cautions, convictions or investigations:

Any information given will not necessarily prevent employment and all circumstances will be considered. As a condition of
employment with Dohatech HealthService you are required to have an enhanced DBS check, details of which may be
confidentially disclosed to clients you engage with throughout your employment. In the event of inconsistencies with the
information provided to that recorded with the Disclosure and Barring Service your application may be invalidated or
employment terminated. (Continue on a separate sheet if needed)
Signed: Date: / /
Data Privacy
Dohatech HealthService processes your personal information to provide you with job placement services, for staff
administration purposes, to maintain its contractual or business relationships with you and for accounts & records, to
assess your suitability for a position or task and to provide you with training opportunities, for personal improvement,
selection and appraisal purposes and to improve the quality and performance of the services that we provide; and for the
management and defence of legal claims and actions, compliance with court orders and other legal obligations and
regulatory requirements. Dohatech HealthService processes sensitive and personal information only if required to comply
with legal obligations or with your consent. We may disclose your personal information to our clients, other Dohatech
branches, to subcontractors who perform services on our behalf and where we are otherwise required to do so, such as a
court order.
I acknowledge and confirm my acceptance that personal data relating to myself, whether obtained from myself or from
any other source, will be retained by Dohatech HealthService and used in accordance with our business as laid out above.
Signed: Date: / /
Disciplinary Action
Have you ever been subject to or are currently undergoing any disciplinary action by an employer?
Yes  No 
When seeking references, we will specifically ask about any disciplinary offences and failure to disclose information that is
subsequently brought to our attention may result in rejection of application or termination of employment.
Signed: Date: / /
APPLICATION
14 Alamein Road,
Occupational Health
Have you suffered or suffer any of the following? Please tick √ If ‘Yes’ please give details
Epilepsy, fits, blackouts, fainting or unexplained loss of  Yes  No

consciousness?
Vertigo, dizziness or problems with balance  Yes  No
Chest pain, angina, heart disease or breathlessness?  Yes  No
Asthma, bronchitis, emphysema, pneumonia or any  Yes  No

other respiratory problems?
Jaundice or any form of hepatitis or other liver  Yes  No
problem?
Any metabolic disorder including diabetes, thyroid and  Yes  No
adrenal gland disease?
Mental Illness, anxiety or depression?  Yes  No
Physical Injury?  Yes  No
Back Pain or Injury?  Yes  No
Any operations or surgical procedures?  Yes  No
Any other medical condition which may adversely affect  Yes  No

you or anyone you may come into contact with?
Have you had any periods in hospital within the last 3  Yes  No
years?
Are you receiving treatment, medication or under  Yes  No
medical supervision for any condition?
Declaration
I authorise Dohatech HealthService to take references and if appropriate complete further checks to verify information I
have provided and to give its clients relevant information relating to my employment details or this application. I
understand that any misrepresentation or omission of any material fact or deception will be cause for immediate
cancellation of consideration for employment or dismissal if I am already employed.
I understand that my registration is subject to the receipt of satisfactory references and an enhanced DBS and I agree to
inform Dohatech HealthService should I be convicted or cautioned of an offence during my employment.
I agree to inform Dohatech HealthService immediately should I engage any other employment following introduction by
Dohatech HealthService, to include being offered permanent employment following a temporary assignment.
I understand data privacy and agree to adhere to confidentiality of any information I have may have access to at all times.
I declare that the information given on this form is complete and accurate
Signed: Date: / /
APPLICATION
14 Alamein Road,
Declarations
Name:
Role:
As part of applying for work with Dohatech HealthService, I understand that I will have to undergo Standard or
enhanced checks through Disclosure and Barring Service and that the cost of £54.00 to cover payment of my
disclosure will be deducted from my wages.
I also agree upon receipt of my disclosure that I will register my certificate for the update service.
I understand that if I do not commence work with Dohatech HealthService, I will be liable to cover the full cost of
my DBS check.
Name: __________________________________________
Role: __________________________________________
As part of applying for a role with Dohatech HealthService, it is a condition that you complete Mandatory Training
this will be issued to you shortly after your Office Appointment. If you fail to start work with Dohatech
HealthService you will become liable for the cost of the training packages that we have issued.
Name:
Role:
I agree to the above declarations and will reimburse Dohatech HealthService any costs incurred if I do not
commence work for the company.
Signed (worker)
Signed (By Dohatech HealthService)
APPLICATION
14 Alamein Road,
Equal Opportunities
Dohatech HealthService operates a diversity culture policy, which means that we employ people solely on
their ability to do the job required. We will not unlawfully discriminate directly or indirectly against people
on the grounds of their gender, sexual orientation, marital status, age or disability, or on the grounds of race,
colour, national origin or religious belief.
The following is for monitoring purposes only and is voluntary. This form will remain confidential and will be
held separately to your application.
If you do not wish to complete this form it will in no way prejudice your application.
Date of Birth: / /
Ethnic Origin: (please indicate by a tick in the appropriate box)
White Mixed Black or Black British
 British  White and Black Caribbean  Caribbean
 Irish  White and Black African  African
 Any other White background  White and Asian  Black British
 Any other mixed background  Any other Black background
Asian or Asian British Other Ethnic groups Not Stated
 Indian  Chinese  I prefer not to specify
 Pakistani  Any other ethnic group
 Bangladeshi
 Any other Asian background
Any other ethnic background: (please describe)
Gender Information: It is unlawful to discriminate on the grounds of transsexual identity, i.e. against
someone who intends to undergo, is undergoing or has already undergone gender
re-assignment.
 Female  Male
Gender re-assignment:
Do you identify yourself as transsexual according to the definition above?
 Yes  No
APPLICATION
14 Alamein Road,
Sexual Orientation:
Which of the following best describes your sexual orientation?

 Heterosexual  Gay/Lesbian  Bisexual  I prefer not to specify
Marital Status:
 Single  Married/Civil Partnership  Divorced  Widowed  Co-habiting
Religion and Belief:

 Christian  Jewish  Hindu  Sikh  Buddhist  Muslim  None
Any other religion or belief: (please describe)
Disability Information: The Equality Act 2010 protects a person with a disability. A person has a disability if he
or she has a physical or mental impairment which has a substantial and long-term
effect on the ability to carry out normal day to day activities.
Do you consider yourself to have a disability according to the definition above?  Yes  No
If yes and if you require specific arrangements to be made to assist you in carrying out your duties please
outline here or if you wish, please state your disability.
APPLICATION
14 Alamein Road,
Confidentiality Agreement Dohatech HealthService Ltd
It is understood and agreed to that the below identified discloser of confidential information may provide
certain information that is and must be kept confidential. To ensure the protection of such information, and
to preserve any confidentiality necessary under patent and/or trade secret laws, it is agreed that
1. The Confidential Information to be disclosed can be described as and includes:
Invention description(s), technical and business information relating to proprietary ideas and inventions,
ideas, patentable ideas, trade secrets, drawings and/or illustrations, patent searches, existing and/or
contemplated products and services, research and development, production, costs, profit and margin
information, finances and financial projections, customers, clients, marketing, and current or future business
plans and models, regardless of whether such information is designated as “Confidential Information” at the
time of its disclosure.
2. The Recipient agrees not to disclose the confidential information obtained from Dohatech HealthService
Ltd to anyone unless required to do so by law.
3. This Agreement states the entire agreement between the parties concerning the disclosure of Confidential
Information. Any addition or modification to this Agreement must be made in writing and signed by the
parties.
4. If any of the provisions of this Agreement are found to be unenforceable, the remainder shall be enforced
as fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent
required to permit enforcement of the Agreement as a whole.
WHEREFORE, the parties acknowledge that they have read and understand this Agreement and voluntarily
accept the duties and obligations set forth herein.
Recipient of Confidential Information:

Name (Print or Type): Dohatech HealthService Directors (only)
Signature:
Date:
Discloser of Confidential Information:
Name (Print or Type):
Signature:
Date:
APPLICATION
14 Alamein Road,
APPLICATION
14 Alamein Road,

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APPLICATION

Dohatech Health Services

EXPERIENCE OUR COMMITMENT TO EXCELLENCE

Dear: Prospective Candidate

Email: info@dohatechealthservice.co.uk / dohatechealthservice@gmail.com

Please complete all sections using CAPITAL LETTERS

Mr  Mrs  Miss  Ms  Surname:

Forename(s): Any Names Previously Used:

Current Address Contact Details

Date of Birth: / / Do you Require a Visa to Work in the UK?

Nationality: Fluent Languages than English?

Name: Relationship to You:

From To (mm/yy): Name of School/College/University: Course/Qualification:

Please Explain Any Gaps

From: To: Postcode:

Reason for Leaving:

Can we contact them before interview? Yes  No 

Please Explain Any Gaps

From: To: (mm/yy) Postcode:

Reason for Leaving:

Can we contact them before interview? Yes  No 

Please Explain Any Gaps

From: To: (mm/yy) Postcode:

Reason for Leaving:

Can we contact them before interview? Yes  No 

Please Explain Any Gaps

From: To: (mm/yy) Postcode:

Reason for Leaving:

Can we contact them before interview? Yes  No 

Course: Date Expiry Date: Organising Body:

(Employee) (On behalf of Dohatech HealthService)

Rehabilitation of Offenders Act

Please give details of any cautions, convictions or investigations:

Epilepsy, fits, blackouts, fainting or unexplained loss of  Yes  No

Chest pain, angina, heart disease or breathlessness?  Yes  No

Asthma, bronchitis, emphysema, pneumonia or any  Yes  No

Physical Injury?  Yes  No

Back Pain or Injury?  Yes  No

Any operations or surgical procedures?  Yes  No

Any other medical condition which may adversely affect  Yes  No

Signed (By Dohatech HealthService)

Ethnic Origin: (please indicate by a tick in the appropriate box)

White Mixed Black or Black British

 British  White and Black Caribbean  Caribbean

 Irish  White and Black African  African

 Any other White background  White and Asian  Black British

 Any other mixed background  Any other Black background

Asian or Asian British Other Ethnic groups Not Stated

 Indian  Chinese  I prefer not to specify

 Pakistani  Any other ethnic group

 Any other Asian background

Any other ethnic background: (please describe)

Which of the following best describes your sexual orientation?

Religion and Belief:

Confidentiality Agreement Dohatech HealthService Ltd

Recipient of Confidential Information:

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