Please provide details of two professional referees we can contact, one of which must be your current / most recent employer. At least one reference must be from a similar background to the job that you are applying for. Please note, we will NOT accept reference from family members or friends.
Referee 1 - Current / Most Recent Employer
Referee 2


As an employer we are required to make basic checks on everyone we intend to employ and you will be required to supply the relevant right to work documents.
Under the terms of the Immigration, Asylum and Nationality Act 2006, we have a responsibility to prevent illegal working in the UK by ensuring that our employees have the right to work in the UK.
We will require the following documents to verify your identity and prove your right to work in the UK. You can view the full list here.
  • Identification - Passport
  • Residence - Utility Bill, Bank Statement, Council Tax Bill/Statement, Mortgage or Rent Statement, Tenancy Agreement
  • Right to Work - Visa/Work Permit, Home Office
Work Pattern Preferences
Employment History:
Please provide 10 years Continuous Employment History. Where the previous employment is NOT Continuous and there are gaps in employment, please provide a full explanation in the section provided below. Current / Most Recent Employer First

1. Employer

2. Employer

3. Employer

4. Emplyoer

5. Employer

Competency & Experience:
Please provide written details of the areas in which you have gained experience and competency in, Please ensure you state where you gained (including the length) this experience.
Training & Development
Please tick all training that has been carried out within the last 12 months. You will be asked to provide copies of certification if you are invited for interview. If successful and you do not possess copies, then you will be required to undertake the training again.

Declaration Section

I am able to confirm that the information I have given on this form relation to my experience, competency, length of experience, areas of clinical expertise and training undertaken for the specific areas selected is correct and complete, and any misleading statements or information may be sufficient in cancelling any agreements made. I am also aware that where I do not feel competent or feel that I require further training in a specific area, that I will declare this before accepting any placements in an NHS or similar hospital type setting or where specific expertise is required.
Fitness to Practice:
I confirm that I know not of any impairment of my fitness to practise, including misconduct, lack of competence or ill health.
Immunisation Type
(Please provide details of your immunity – if successful, you will be asked to provide copies of your immunisation status)
Dose 1
Dose 1
Dose 1
Dose 1
Dose 2
Dose 2

Rehabilitation of Offenders Act 1974:

JAAN Services aims to promote equality of opportunity for all applicants with the right mix of talent, skills & potential. Having an ‘unspent’ conviction will not necessarily bar you from employment, this will depend on the circumstances and background to your offence(s). As JAAN Services meets the requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974, all applicants who are offered employment will be subject to an Enhanced Disclosure Check via the Criminal Records Bureau / Disclosure Scotland before appointment is confirmed. This includes details of cautions, reprimands or final warnings, as well as convictions. Have you ever been convicted by the courts, cautioned, reprimanded, or given a final warning by the police?
Data Protection:
I understand that the information I have provided to JAAN Services will be held securely and treated sensitively in accordance with The Data Protection Act 1998. In addition, I understand that there may be instances in which personal data held will be accessed for the purposes of external audits / inspections from Professional Bodies, such as CQC to ensure compliance with statutory and regulatory requirements. Should I work within the NHS I give permission for NHS PASA to access my file for auditing purposes.
Equality and diversity monitoring form
JAAN Services wants to meet the aims and commitments set out in its equality policy. This includes not discriminating under the Equality Act 2010, and building an accurate picture of the make-up of the workforce in encouraging equality and diversity. The organisation needs your help and co-operation to enable it to do this, but filling in this form is voluntary. The information you provide will stay confidential, and be stored securely and limited to only some staff in the organisation’s Human Resources section.
Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box
The information in this form is for monitoring purposes only. If you believe you need a ‘reasonable adjustment’, then please discuss this with your manager, or the manager running the recruitment process if you are a job applicant.


By completing and submitting this application you are authorising a member of JAAN Services Umbrella to contact you/and the agency regarding the completion of your registration.