Application Form

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About Matrix Staffing Solutions Limited

Matrix Staffing Solutions Limited and is a dedicated recruitment agency committed to supplying skilled, reliable, and compassionate staff to a range of care settings across the UK, including nursing homes, residential care facilities, hospitals, and supported living services.

We recognise that high-quality care begins with the right people. For this reason, we focus on recruiting individuals who not only meet the required qualifications and experience but also demonstrate professionalism, empathy, and a strong commitment to delivering person-centred care.

As part of our team, you will play a vital role in supporting vulnerable individuals and maintaining the high standards of care our clients expect. We are committed to supporting our staff through ongoing guidance, compliance checks, and access to opportunities that promote both personal and professional development.

At Matrix Staffing Solutions Ltd, we value integrity, reliability, and teamwork. We aim to build long-term relationships with our employees, ensuring you feel supported, respected, and confident in your role.

Position Applied For

Chef

Domestic Assistant

Front of House

Healthcare Assistant

Housekeeping

Kitchen Assistant

Night Porter

Nurse

Senior Healthcare Assistant

Personal Details

First Name *

Last Name *

Street Address *

City

County / State

Post Code *

Country

Mobile *

Email Address *

Eligibility & Suitability

Are you eligible to work in the UK? (Evidence will be required)

Yes

If offered the position, would you continue in any other employment?

Yes

Do we need to make any disability-related adjustments to allow you to take part in the recruitment process?

Please indicate when you would like to work

Part-Time

Full-Time

Daily

Employment History (most recent first)

1. Employer

Name and address of employer

Job Title

From (MM/YYYY)

To (MM/YYYY)

2. Employer

Name and address of employer

Job Title

From (MM/YYYY)

To (MM/YYYY)

3. Employer

Name and address of employer

Job Title

From (MM/YYYY)

To (MM/YYYY)

4. Employer

Name and address of employer

Job Title

From (MM/YYYY)

To (MM/YYYY)

5. Employer

Name and address of employer

Job Title

From (MM/YYYY)

To (MM/YYYY)

Education

Schools

School

From

Examinations Passed / Grades

School

From

Examinations Passed / Grades

Further Education (College / University)

College / University

From

Qualifications Gained / Grades

College / University

From

Qualifications Gained / Grades

Relevant professional qualifications / training / memberships (with dates and levels). Indicate where these are currently being continued.

Other training or courses relevant to the post (which did not lead to a qualification)

NMC Registration (For Nurses Only)

NMC Number

Date of Registration

Date of Next Renewal

Equal Opportunities & Health

Matrix Staffing Solutions Limited is an Equal Opportunities Agency. The criteria for selection are solely based on the applicant's suitability and competence for the job for which they are applying. We are required by law to monitor the effectiveness of our Equal Opportunities policy and, should your application be successful, we will ask you to complete a short, confidential questionnaire.

Health: If you are made an offer of employment, you will be asked to complete a Medical Screening Questionnaire. The information will be treated as strictly confidential. You must disclose all relevant information as failure to do so may affect your probationary review.

Declaration under the Protection of Freedoms Act 2012

The post for which you are applying is a 'regulated activity' within the meaning of Part 5 Chapter 1 of the Protection of Freedoms Act 2012, and it is a criminal offence for a 'barred person' to apply to work in a regulated activity. If you are a barred person you must not proceed with this job application.

Having a criminal record does not automatically preclude you from securing employment in the health and social care sector. Many roles are exempt from the Rehabilitation of Offenders Act 1974 and require DBS checks which will disclose all convictions, cautions, reprimands and final warnings which are not protected.

Do you have any outstanding safeguarding investigations or suspensions, criminal prosecutions or convictions that might lead to your being barred from working with children or protected adults?

Yes

Do you have any convictions, cautions, reprimands or final warnings that would not be filtered in line with current guidance?

Yes

Surname (print) *

Forenames (print) *

Date *

If your application is successful, you will be required to provide a satisfactory enhanced DBS disclosure. Matrix Staffing Solutions Limited will offer full support throughout this process. A copy of the DBS Code of Practice is available upon request. You will sign for this declaration together with the Privacy Notice at the end of this section.

References (References will only be taken after an offer of employment has been made)

Please give three referees (not relatives or friends). At least one should be your current or last employer relating to a period of not less than 3 months. All offers of employment are conditional upon receipt of at least two satisfactory references.

Employer Reference 1

Name and Job Title (of relevant manager)

Email Address

Organisation and Address

From

Employer Reference 2

Name and Job Title (of relevant manager)

Email Address

Organisation and Address

From

3. Character Reference

Your character referee must not be a relative or a close friend. Please give someone who knows you in a professional, academic, voluntary or community capacity — for example a former colleague, supervisor, tutor, or someone who has known you through a club, place of worship or community group.

Full Name *

Relationship to you *

Email Address

Mobile Number

I confirm this referee is not a relative or a close friend. *

Privacy Notice & Declaration

Privacy Notice. We process personal data relating to those who apply for job vacancies with us or who send speculative applications. We do this for employment purposes, to assist us in the selection of candidates, and to assist in running the business. The data may include identifiers such as name, date of birth, personal characteristics, qualifications and previous employment history.

We will not share any identifiable information about you with third parties without your consent unless the law allows or requires us to do so. The personal data provided during an application process will be retained for at least six months or, if required by law, for as long as is required. This privacy notice does not form part of an employment offer or contract. If we make an employment offer, we will provide further information about how we handle personal information in an employment context separately.

If you would like to find out more about our data retention policy, see a copy of the information we hold, or have any questions regarding data protection, please email us with the subject "Data Protection Request".

DECLARATION

I understand that the data I have given will be processed and used in accordance with the General Data Protection Regulations and hereby give permission for my details to be processed for the purpose of processing my application.

I confirm that to the best of my knowledge and belief, the information I have given is correct. I hereby give Matrix Staffing Solutions Limited permission to contact my referees and understand that any contract given to me is based on the information provided.

Full Name *

Date *

Adopt your signature

Type your full name and choose a signature style. This becomes your electronic signature and is applied wherever you confirm a declaration on this form.

Full name *

Signature style

Signature

Preview:

Your signature

This single signature confirms both the Criminal Records Declaration above and this Privacy Notice & Declaration.

Tick the box to apply your signature.

I confirm this is my electronic signature and I agree to this declaration.

To help reduce costs we do not acknowledge receipt of application forms. If you have not heard from us within 4 weeks, please assume that you have been unsuccessful. Thank you for applying.

Declaration of Other Employment

First Name *

Last Name *

Date of Birth *

Any other employment or work in any other place

Do Not

If yes, please give details below including where you work and how many hours

Date *

Signature

Tick the box to apply your signature.

I confirm this is my electronic signature and I agree to this declaration.

It is YOUR responsibility to notify Matrix Staffing Solutions Limited if your circumstances change.
Failure to disclose or make a false declaration constitutes serious misconduct.

Employee Contact Details

Your Details

Full Name *

Date of Birth *

Job Title (Position Applied For)

Address

Mobile Tel *

NI Number *

Email Address

ID (Passport, Birth Certificate)

Yes

Nationality

Visa / Work Permit / IND

Yes

Visa Expiry Date

Emergency Contact

Name *

Relationship *

Address

Mobile Tel *

Date

Signature

Tick the box to apply your signature.

I confirm this is my electronic signature and I agree to this declaration.

Equality and Diversity Monitoring

In accordance with its Equal Opportunities statement, the Agency provides equal opportunities and does not discriminate either directly or indirectly on the grounds of race, colour, ethnic origin, nationality, sex, marital status, disability, sexual orientation, religion or age.

The monitoring form does not form part of your application and will be detached and stored separately. You may decline to answer any of these questions. All information will be treated in confidence and used solely by HR for Equal Opportunities monitoring statistics.

Thank you for your assistance in completing this form.

Gender

Female

Male

Prefer Not To Say

Marital Status

Civil Partnership

Married

Single

Other

Prefer Not To Say

Age Band

16 – 24

25 – 39

40 – 49

50 – 59

60 – 65

Over 65

Prefer Not To Say

Disabilities

None

Physical Disability

Mental Disability

Prefer Not To Say

Ethnicity

African

Asian British

Bangladeshi

Black British

British

Caribbean

Chinese

English

European

Indian

Irish

Pakistani

Scottish

Welsh

White & Asian

White & Black African

White & Black Caribbean

Other

Sexual Orientation

Heterosexual

Gay Woman / Lesbian

Gay Man

Bisexual

Prefer Not To Say

Religion or Belief

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

No Religion or Belief

Prefer Not To Say

For the purpose of compliance with the Data Protection Act 1998, I hereby confirm that by completing this form I give my consent to the company processing the data supplied on this form for the purpose of Equal Opportunities monitoring.

Date

Signature

Tick the box to apply your signature.

I confirm this is my electronic signature and I agree to this declaration.

HMRC Starter Checklist

Instructions for employees: Your employer needs the information on this form before your first payday to tell HMRC about you and help them use the correct tax code. Do not send this form to HMRC.

1. Last Name *

2. First Name(s) *

Do not enter initials or shortened names.

3. Gender

Male

Female

4. Date of Birth *

7. Employment Start Date

5. Home Address

6. National Insurance Number (if known)

Employee Statement (select one)

A. This is my first job since last 6 April and I have not been receiving taxable Jobseeker's Allowance, Employment and Support Allowance, taxable Incapacity Benefit, State or Occupational Pension.

B. This is now my only job but since last 6 April I have had another job, or received taxable Jobseeker's Allowance, Employment and Support Allowance or taxable Incapacity Benefit. I do not receive a State or Occupational Pension.

C. As well as my new job, I have another job or receive a State or Occupational Pension.

Student Loan

9. Do you have a student loan which is not fully repaid?

Yes

10. Are you repaying directly to the Student Loans Company by agreed monthly payments?

Yes

11. What type of student loan do you have?

Plan 1

Plan 2

Plan 1 if you lived in Scotland/Northern Ireland when you started, or England/Wales and started before September 2012. Plan 2 if England/Wales and started on or after 1 September 2012.

12. Did you finish your studies before the last 6 April?

Yes

Full Name *

Date *

Signature

Tick the box to apply your signature.

I confirm this is my electronic signature and I agree to this declaration.

Medical Questionnaire

All medical information will be treated as CONFIDENTIAL. The purpose of this questionnaire is to establish your medical fitness for work. We may recommend adjustments or assistance because of this assessment to enable you to do your job.

Name *

Job Title

Any back or musculoskeletal problems causing you difficulty with bending, lifting or standing for long periods?

Yes

Do you have Diabetes?

Yes

Do you have Dyslexia?

Yes

Do you have Eye Problems?

Yes

Do you have Hearing Problems?

Yes

Do you have High/Low Blood Pressure?

Yes

Do you visit your doctor regularly or have had a hospital stay in previous years?

Yes

Any known skin conditions, allergies to skin cleansing products, latex, or other glove problems?

Yes

Have you ever had a positive test for a blood-borne virus that could be transmitted by a contamination incident (TB, HIV, Hep B or C)?

Yes

Do you have a history of anxiety, depression, drug/alcohol misuse or stress-related problems?

Yes

Do you have any other health issues, serious injuries or disability for which you require support?

Yes

Do you need any special aids/adaptations to assist you at work, whether or not you have a disability ("a physical or mental impairment which has a substantial and long-term adverse effect on your ability to carry out normal day to day activities")?

Yes

For those working in residents' areas or with clinical materials

Vaccinated against Hepatitis B? Include dates of vaccination:

Vaccinated against TB? Include dates of vaccination:

Any health conditions that may affect your ability to undertake night and/or shift work?

Employee Declaration

I am aware of the risk from vaccine preventable infections that may be acquired in the course of my work and the potential benefits of vaccination.

I understand that I need to arrange an appointment with my GP to discuss / be given the above stated immunisation(s).

I understand I must inform my manager that I have declined a vaccination that is recommended for my role, so that adjustments can be made to reduce any risk of contact with these vaccine preventable infections where possible.

I hereby declare that all the information provided by me in this questionnaire is true. I understand that any distortion of fact can result in the termination of my employment.

Date *

Your Signature

Tick the box to apply your signature.

I confirm this is my electronic signature and I agree to this declaration.

New Starter & Bank Details

Please complete in CAPITAL LETTERS.

Employee Details

Title

First Name *

Last Name *

Date of Birth

Email Address

Home Address

Post Code

NI Number

Tax Code (if known)

P45 or P46

Employee Bank Details

Bank *

Account Holder Name *

Sort Code *

Account Number *

Name of Employee *

Signature

Tick the box to apply your signature.

I confirm this is my electronic signature and I agree to this declaration.

By clicking Submit Application below, you confirm that all the information you have provided is true and complete to the best of your knowledge.

Application Form

Schools

Further Education (College / University)

Adopt your signature

Declaration of Other Employment

Employee Contact Details

Equality and Diversity Monitoring

HMRC Starter Checklist

Medical Questionnaire

New Starter & Bank Details

Save & finish later

Application Submitted

Submission Failed