A24 Group Form – Fill Out and Use This PDF

EFFECTIVE 02/08/12

PERSONAL DETAILS

How did you hear of the A24 Group?

Have you ever worked for us previously?

1

A24 Group retains the right to hold this application and any other data required to process this application (whether in the RSA, UK, European Union or elsewhere) and keep for as long as necessary in line with the Data Protection Act.

A copy of this can be requested in writing and is charged at a fee of R100 per request.

A24 Group may contact you to advise information of interest or to share your information with Ambition related companies.

PROFESSIONAL REFERENCES

A24 Group requires references from your last or most recent employer.

MEDICAL HISTORY

LANGUAGES

Third Language

OTHER QUALIFICATIONS / TRAINING

You should supply any certificates. Please continue on a separate sheet.

Qualification or Course

Training Establishment

Date / / /

2

EMPLOYMENT HISTORY

Please give details of employment history during the past 5 years, most recent first. (All gaps must be accounted for - please continue on blank paper if necessary).

3

PLEASE TICK THE AREAS THAT DESCRIBE YOUR WORK EXPERIENCE. PLEASE REMEMBER THAT YOU WILL BE HELD PROFESSIONALLY ACCOUNTABLE

Are You: (Please tick and attach proof of SANC Registration)

KEYWORDS (PLEASE TICK) (Only tick according to your most recent experience within the last 2 years for placements)

4

KEYWORDINGKEYWORDINGFOR CARE GIVERSFORCAREANDGIVERSSUPPORT STAFF

When did you apply for registration?

5

KEYWORDING FOR SUPPORT STAFF

KEYWORDING FOR SOCIAL WORKERS ONLY

PLEASE TICK THE AREAS THAT DESCRIBE YOUR WORK EXPERIENCE. PLEASE REMEMBER THAT YOU WILL BE HELD PROFESSIONALLY ACCOUNTABLE

6

BANK DETAILS

Name of account holder

Bank name

Account type

DECLARATION

I declare that the information given in this application form is true and complete to the best of my knowledge and belief.

I have read and understand and agree to the following:

•฀ I฀have฀read฀and฀understood฀and฀agree฀to฀adhere฀to฀the฀Contract฀for฀Services฀for฀temporary฀workers฀and฀I฀specifically฀confirm฀that฀I

am familiar with the Disciplinary code.

•฀ Professional฀Indemnity฀–฀I฀understand฀that฀I฀need฀to฀have฀professional฀indemnity฀cover฀in฀place฀at฀all฀temporary฀assignments฀and I will not undertake assignments without ensuring that this cover is in place. I understand that my Professional Indemnity must cover any needle stick incidents as well.

•฀ RWOPS฀–฀If฀I฀am฀employed฀in฀the฀public฀service,฀I฀understand฀the฀need฀to฀obtain฀permission฀to฀undertake฀agency฀work฀from฀my฀฀

employer, prior to undertaking any assignments.

•฀ I฀agree฀to฀comply฀with฀the฀current฀Occupational฀Health฀&฀Safety฀Act฀(OHSA).

•฀ In฀accordance฀with฀the฀Criminal฀Law฀(Sexual฀Offences฀and฀Related฀Matters)฀Amendment฀Act฀32฀of฀2007฀if฀the฀Temporary฀Worker has at any time been convicted of a sexual offence against a child or a person who is mentally disabled (including persons who have been declared patients of a Judge in Chambers and who are alleged to have committed a sexual offence against a child or

a mentally disabled person) the Temporary Worker must without delay immediately disclose such conviction or finding to the A24 Group. The Temporary Worker confirms that they have never been convicted of any sexual offence against a child or a person who is mentally disabled (including patients of a Judge in Chambers as outlined above), and will without delay immediately disclose such conviction or finding to the A24 Group.

•฀ In฀accordance฀with฀Childrens฀Act฀No.฀38฀of฀2005฀the฀Temporary฀Worker฀must฀without฀delay฀immediately฀disclose฀to฀the฀A24฀Group if his or her name appears in Part B of the National Child Protection Register issued by the Director-General. The Temporary Worker confirms that his or her name does not appear in Part B of the National Child Protection Register, and will without delay immediately disclose to the A24 Group should his or her name be added to Part B of the National Child Protection Register.

•฀ I฀understand฀that฀my฀appointment฀is฀subject฀to฀the฀receipt฀of฀a฀minimum฀of฀two฀satisfactory฀references.

•฀ I฀agree฀to฀respect฀the฀confidentiality฀of฀patients฀and฀clients฀and฀any฀other฀information฀that฀I฀may฀have฀access฀to฀at฀all฀times.

•฀ I฀consent฀to฀the฀A24฀Group฀checking฀the฀details฀I฀have฀provided฀in฀support฀of฀this฀application฀against฀the฀various฀data฀sources฀฀ ฀

in order to verify my identity and process this application. These details may be recorded and used to assist other organisations for

identity verification purposes such as the HPCSA / Nursing Council/etc...

Date

Please sign between the lines ONLY.

Your signature is required for producing an ID badge.

7. CONDUCT OF ASSIGNMENTS

7.1.The Temporary Worker is not obliged to accept any Assignment offered but if he does so then during every Assignment and afterwards where appropriate, he will:-

a)co-operate with the Client and/or the Client’s staff, accept reasonable instructions and accept the direction, supervision and control of any responsible person at the Client’s organization;

b)be present at such times as may be stipulated by the Client and unless arrangements have been made to the contrary, to conform to the normal hours of work/shift pattern agreed at the premises where the Assignment is carried out;

c)observe any relevant rules and regulations of the Client’s establishment (including normal hours of work) to which attention has been drawn or which the Temporary Worker might reasonably be expected to ascertain;

d)take all reasonable steps to safeguard his own health and safety and that of any other person who may be present or affected by his actions on the Assignment and comply with the Health & Safety policies and procedures of the Client;

e)not engage in any conduct detrimental to the interests of the Client;

f)not at any time divulge to any person, nor use for his own or other persons benefit, any confidential information relating to the Clients or the Agents employees, business affairs, transactions or finances;

g)act in a professional and courteous manner;

h)wear a uniform and badge as required;

i)be responsible for the provision of any necessary equipment;

7.2.If the Temporary Worker is unable to attend work during the course of an Assignment he should inform the Client and the Agent as soon as possible and no later than 3 hours before the start of the Assignment. The Agent is available 24 hours a day, 7 days a week.

8. TERMINATION OR COMMENCEMENT

8.1.Before commencing any Assignment the Temporary Worker must provide the Client, via the Agent, with confirmation that he has the relevant professional qualifications as required by their professional body.

8.2.The Temporary Worker will fully co-operate with the Agent in relation to any criminal record and/or credit checks which the Client may be required to carry out.

8.3.Before commencing any Assignment the Temporary Worker must inform the Client, via the Agent, about any complaint made against him that is relevant to their professional competence, standing or conduct. In the event that the Temporary Worker becomes the subject of a complaint he must inform the Client, via the Agent, immediately and provide regular reports about the progress of proceedings.

8.4.The Agent will inform the Temporary Worker about any complaint made against him that is relevant to his professional conduct or competence.

8.5.Where the Temporary Worker wishes to raise a complaint or grievance about any matter he should do so in accordance with the Agents complaints procedure.

8.6.Unless otherwise agreed the Temporary Worker or the Client may, without prior notice or liability, terminate the Assignment at any time.

8.7.If the Temporary Worker does not inform the Agent should they be unable to attend the Clients premises during the course of an Assignment this will be treated as termination of the Assignment by the Temporary Worker.

8.8.If the Temporary Worker is absent during the course of an Assignment and the contract has not been otherwise terminated the Client will be entitled to terminate the contract in accordance with clause 8.6 if the work to which the absent Temporary Worker was assigned is no longer available.

9. SPECIAL PROVISIONS

9.1.The Temporary Worker must provide the Agent with all requested proof of qualifications, references, recent photographs, access of health information and medical registrations as may be requested in order for the Agent to satisfy itself that the Temporary Worker is fit to be supplied to Clients. The Temporary Worker accepts that the Agent is or may be required to handle/process this (and other personal information as reasonably requested from time to time) and may need to share this information with its associates, agents or third parties as part of performing its duties.

9.2.In the situation where the Temporary Worker has professional qualifications and relies theron for agency work, he must ensure full and current compliance with the appropriate professional requirements.

9.3.The Temporary Worker must have valid professional indemnity insurance cover, if he is professionally qualified.

9.4.The Temporary Worker should advise the Agent immediately if offered any employment or engagement by the Client or any third party to whom he is introduced by the Client and is also requested to provide details of the Agent of any remuneration offered. The Temporary Worker shall not have any dealings with the Client without informing the Agent. Should the Temporary Worker fail to do so, the Agent shall recover from the Temporary Worker any commission it would have earned.

9.5.The Temporary Worker is required to advise the Client via the Agent of any medical condition or any change in state of health that could impact upon the ability to carry out Assignments or his eligibility for Assignments.

9.6.The Temporary Worker must follow and co-operate fully with the formal induction process of the Client and undertake any training specified by the Client.

9.7.Throughout each Assignment, the Temporary Worker must comply with the Client’s policies and/or procedures.

9.8.The Temporary Worker hereby agrees to disclosures of personal information about the Temporary Worker as required in order for the Agent to comply with all prevailing legislation.

9.9.Each of the Agents in clause 1 are associated companies but operate independently from each other. This means that they can provide two types of Assignment opportunities. Ambition 24 hours provides very much last minute Assignments at higher hourly rates of pay, The Nursing Services of South Africa provides longer term contract Assignments at lower hourly pay rates. The consultants will inform you of your rate of pay at the point of booking.

9.10.In order to maximize your opportunities for work Assignments your details will be made available to both Agents.

10. LAW

These terms are governed by the law of the Republic of South Africa and are subject to the exclusive jurisdiction of the courts of the Republic of South Africa.

CONTRACT OF SERVICES FOR TEMPORARY WORKERS

This Contract of Services is acknowledged and accepted. I further acknowledge that the Agent provides this Contract on behalf of the Client.

SIGNED BY TEMPORARY WORKER

7695J/0810

DISCIPLINARY ACTION FOR OTHER MISCONDUCT

Any misconduct not specifically covered in the code will be dealt with according to the seriousness of the offence.

NOTE:

The code makes provision for progressive disciplinary actions in each category of offence. Discipline will therefore be taken progressively in each of offence and not necessarily only in regard to a specific offence. The disciplinary action prescribed by the code may be deviated from where justified by the particular circumstances of the case. Accordingly, such action may be more severe than the prescribed guideline where aggravating circumstances exist, or less severe where mitigating circumstances exist. In certain circumstances and in the case of certain offences, dismissal even for a first offence would be appropriate.

Last reviewed 1 March, 2012