APPLICATION FORM

POSITION
APPLIED FOR: DEPUTY MANAGER
LOCATION: Broome End Brook House Clevedon Court
The following information will be treated in the strictest confidence.
PERSONAL
(Please complete this section in BLOCK CAPITALS)
Surname: MIR First Name(s): USMAN MUSHTAQ

Address: LOWER PLATE WARD NO 10 MUZAFFARABAD

Postcode: 13100
Contact Tel. No: +923421950915 Mobile Tel. No: +923421950915

National insurance number: 8220366277943 Email Address: usmanmirajk11@gmail.com

Full Driving Licence: YES/NOEndorsements: YES/NO
If YES, please give further details including
dates.
Are you involved in any activity which might limit your YES/NO
availability to work
or your working hours e.g. local government?
If YES, please give
full
details.
Are you willing to work overtime and weekends if required? YES/NO
Please give details of any hours which you
would not wish to work:
Have you any convictions (other than spent convictions under YES/NO
the Rehabilitation of Offenders Act 1974)? If Yes? Please
complete
Disclosure & Barring Services form attached
You may be required, if offered employment, as part of your YES/NO
Application
to complete a Pre-Employment Medical Questionnaire. Are
you happy to complete this?
Have you ever worked for this Company before? YES/NO
If YES, please give full details
Do you need a work permit to take up employment in the UK? YES/NO
How much notice are you required to give to
your current employer? ONE WEEK PRIOR
Have you read our Equal Opportunity
Policy? (If you have not please inform the YES/NO
nurse in charge, so they can make this
Curaa Group Ltd; Companies House: 10923889
27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 1
available to you)

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 2
Education

College or University From To Courses and

Results
Sir Syed Model School & JUNE 2018 AUGUST 2020 ICS PASSED WITH B
College Haripur GRADE(65%)

Sir Syed Model School & SCIENCES PASSED WITH

College Haripur APRIL 2016 MAY 2018 A GRADE (76%)

Further Formal Training From To Diploma/

Qualification

COMSATS Institute of OCT 2020 OCT 2021 1 YEAR DIT PROGRAM

Computer Technology PASSED WITH A+ GRADE
(94%)

Job related Training Qualification i.e in

Courses SUBJECT house training or
NCFE/ NVQ etc

IELTS VALID FROM MAY 2022 VALID TILL MAY 2024 OVERALL 6 BAND
Listening 6.5
Speaking 6.0
Writing 6.0
Reading 5.5

Please give details of membership of any technical or professional associations:

UKCC – PIN number (for trained staff)

Please list any languages spoken and the level of competence:

FLUENT IN ENGLISH

NATIVE LANGUAGE URDU

Curaa Group Ltd; Companies House: 10923889
27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 3
Employment History

Please give details of your past employment (5 years), excluding your present or last employer, stating
the most recent first.

Name and address of Dates Position held/Main duties Reason for leaving
employer
MUZAFFARABAD MEDICAL COMPLEX JAN 2021- MEDICAL ATTENDANT AND MY SELF GROWTH
AND ADDRESS IS AMBORE PRESENT DUTIES ARE SOME OF MY DUTIES ARE
MUZAFFARABAD
 Managing people with challenging
& anti-social behaviour
 Managing people with mental health
problems including Dementia
 Managing people with physical
disabilities

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 4
PRESENT OR LAST EMPLOYER

Are you currently employed? YES/NO

Name of present or last employer: MUZAFFARABAD MEDICAL COMPLEX

Address: AMBORE MUZAFFARABAD

Telephone No: +923125642387

Nature of business: HOSPITAL

Job title and a brief description of your

duties: MEDICAL ATTENDANT
SOMEOF MY DUTIES ARE
 Managing people with challenging & anti-social behaviour
 Managing people with mental health problems including Dementia
 Managing people with physical disabilities

Length of Service: 24 From: JAN 2021 To: PRESENT

MONTHS

Assistance With Interview And Assessment

Do you require us to make any special arrangements for you to participate in the
recruitment process? YES/NO
For example, large print forms? Or additional time complete forms?
If yes, please give details:

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 5
 Any offer of employment may be made subject to a satisfactory medical report.
GP's name: Telephone:

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 6
 Address:
Your GP will not be contacted without your permission.

Next Of Kin

Full name: RUQIYA MUSHTAQ

Relationship: MOTHER
Telephone: +923421950915 E-mail: usmanhome144@gmail.com
Address: LOWER PLATE WARD NO 10 MUZAFFARABAD

Identity Details

Nursing and Midwifery Council PIN no. (Nurses only):

National Insurance Number: 822036627743
Passport Number (migrant applicants: LY0997941
Do you require a Vise to work in the UK?
YES/NO

Supplementary Information
Please set out below any further information to support your application, e.g. past achievements, future
aspirations,
personal strengths.
As a Medical Attendant with over 2 years of experience, I bring a comprehensive set of skills that I believe will be valuable to your
company. In my medical attendant role, I honed my abilities in Management skills and Communication skills, providing a firm
foundation for the Deputy Manager position. My communication, people-centric nature, and compassion have afforded me excellent
customer service skills. I also got three times Employee of the month award in my career as well as other achievements.
I also served as a fundraising volunteer for EDHI Center Muzaffarabad to collect funds for childs.

DISCLOSURES
Given the nature of the job applied for, in the event that I am offered the position, I understand that any offer of
employment is subject to information on my criminal record and SOVA listing being disclosed to the Company
The amendments to the Exceptions Order 1975 (2013)
by the Disclosure & Barring Service (DBS).
provide that certain spent convictions and cautions are ‘protected’ and are not subject
to disclosure to employers, and cannot be taken into account.

I have been given a copy of the Company’s Equal Opportunities Policy, which includes information relating
to the recruitment of ex-offenders.
DECLARATION
I declare that the information given in this form is complete and accurate. I understand that any false
information or deliberate omissions will disqualify me from employment or may render me liable to
Curaa Group Ltd; Companies House: 10923889
27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 7
summary dismissal

I understand these details will be held in confidence by the Company, for the purposes of assessing this
application, ongoing personnel administration and payroll administration (where applicable) in compliance
with the Data Protection Act 1998 and

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 8
give my consent to my personal data being held. All personal data will be password protected if
kept electronically and in a locked cabinet if paper, and seen only by the Registered Manager, Deputy
Manager and Administrators and relevant people such as CQC and North Somerset Council for inspection
purposes.

Signature: USMAN MUSHTAQ MIR Date: 02/03/2023

REFERENCES

Please give the names of two people (one of which should be your present or most recent employer)
whom we may approach for a reference.
Can we approach your current employer before an offer of employment is made? YES/NO

Name: FAIQ AZAM Name: SUNAINA RAJPOOT

Position: SUPERVISOR Position: HEAD NURSE
Address: AMBORE MUZAFFARABAD Address: AMBORE MUZAFFARABAD

Tel No: +923125642387 Tel No: +923109356584

Email: faiqwithbiology@gmail.com Email: sunainarajpoor2nd@gmail.com

SOURCE OF APPLICATION

How did you hear of this vacancy? INTERNET

Disclosure & Barring Service (DBS) Form

You must fill in the information below and return this form with your application form. Please read
the attached guidance notes first.

First Name(s) USMAN MUSHTAQ Surname MIR

Position Date 02/03/2023

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 9
 Box A
(Complete only if you have no convictions etc, either spent or unspent. You should note that
this post is exempt from the provisions of the Rehabilitation of Offenders Act 1974. The
amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions
are ‘protected’ and are not subject to disclosure to employers , and cannot be taken into account.
I HAVE NO CONVICTIONS, CAUTIONS, REPRIMANDS, OR FINAL WARNINGS.

As the applicant for the position I confirm that the details shown above are an accurate
record of any criminal offences that may appear on my Disclosure & Barring Service and
understand this will be discussed with the Manager if I am invited to an interview.

Signature USMAN MUSHTAQ MIR (Applicant) Date 02./03./2023

Box B
Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as
defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)

The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and
cautions are ‘protected’ and are not subject to disclosure to employers , and cannot be taken into
account. (Record below details of any and all convictions, spent or unspent, cautions,
reprimands and/or final warnings that you may have to declare

I HAVE THE FOLLOWING CONVICTIONS, CAUTIONS, REPRIMANDS AND/OR FINAL

WARNINGS:

………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

As the applicant for the position I confirm that the details shown above are an accurate
record of any criminal offences that may appear on my Disclosure & Barring Service and
understand this will be discussed with the Manager if I am invited to an interview.

Signature……………………………………………… (Applicant) Date …./……/……

OVERSEAS ADDRESS CHECK – if applicable

APPLICANT NOTIFIED AND OBTAINING RELEVANT CHECK – YES / NO

COUNTRY / COUNTRIES RELEVANT CHECK REQUIRED FROM:

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 1
 As Manager I have discussed with the applicant any details, as recorded above that might
appear on the
applicant’s Disclosure & Barring Service certificate, in line with the DBS Code of Practice.
Printed Name of Manager Position

Signature Date

Applicants must complete a Disclosure & Barring Service form when they apply
for any post where the successful candidate will be required to obtain a certificate
of disclosure from the Disclosure & Barring Service.

Applicants must complete either box A or box B overleaf.

Box A should be completed if the applicant has no convictions (spent or unspent),

cautions, reprimands or final warnings.

Box B should be completed if the applicant has convictions (spent or unspent),

cautions, reprimands or final warnings. The amendments to the Exceptions Order 1975
(2013) provide that certain spent convictions and cautions are ‘protected’ and are not subject to
disclosure to employers , and cannot be taken into account.

Managers must discuss the Disclosure & Barring Service form with each applicant at
interview
- please refer to the DBS Code of Practice. The Manager must countersign the declaration.

OVERSEAS CHECKS FOR SUCCESSFUL CANDIDATE ONLY

If you require a Disclosure & Barring Service from an applicant who has lived
abroad you must access the DBS website and follow the appropriate guidelines to
obtain the overseas checks that are required.
www.gov.uk/government/publications/criminal-records-checks

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 1
 RETENTION OF INFORMATION

Due to the restrictions imposed regarding the storage of disclosure information,

the original of this form for the successful candidate only should be forwarded with
the completed Disclosure & Barring Service application form to the Administrator
for processing.

The original of this form for an unsuccessful candidate must be safely destroyed
and no copy should be taken or retained by the Manager.

Curaa Group Ltd; Companies House: 10923889

27 Old Gloucester Street, London, WC1N 3AX, United Kingdom 1