1. Personal Details Data Protection Statement The personal information (data) collected on this form, and on the attachments, (which includes the collection of sensitive personal data) are collected for the purposes of recruitment, personnel administration (for new employees) and monitoring. Unless you direct otherwise (for example in a situation where you would like this Application kept on file for future vacancies) the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6 months. It is the policy of the Agency to protect, and keep secure, all personal data collected. All personal data is processed for the purposes of recruitment, and, in the case of successful Applicants, for the satisfactory administration of their employment, and for no other purpose. Which of the following applies to you? * RegisteredNurse Healthcare assistant Support Worker NMC pin number Expiry Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20252026202720282029203020312032203320342035 Title Mr Mrs Ms Miss Surname First Name(s) Former Name(s) Gender Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Nationality Current Address Address line 1 Address line 2 City County Postcode Telephone Mobile Phone Email Address If less than 5 years at current address please state previous addresses below including time spent there. Previous addresses Next of Kin Person to be notified in case of emergency Full Name Address Contact Numbers Relationship to you 2. Eligibility To Work Please tick appropriately: Do you hold a British Passport? Yes No Are you a member of the EU? Yes No If you do not have any of the above do you have any of the following: Settlement, Student Visa, Work Permit or other (Please specify in the box below). 3. Formal Education and Qualifications Course of Study/Qualification(s) gained and year e.g. GCSE’s (2014), “A” levels (2014), NVQ (2014), Degree (2014) etc Qualifications Qualifications Qualifications Qualifications Qualifications 4. Employment History Please type details of all your employment for a period of at least the last 5 years, to include all nursing agency memberships, starting with most present employment. Please include reasons for gaps. 5. Mandatory Certificates Please select below: Health & safety Fire Safety Infection control Manual handling Safeguarding Vulnerable Adults Lone Worker 6. Immunisations 7. References Please supply the names of TWO referees. One of the references MUST be a professional referee. First Reference Second Reference Full Name Position Email Address Please state how long this person has know you and in what capacity Full Name Position Email Address Please state how long this person has know you and in what capacity 8. Rehabilitation of Offenders Act As a general rule, no-one need answer questions about spent convictions. However this general rule does not apply to specified professions, employments and occupations. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to: a) any employment or other work which is concerned with the provision of health services and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to persons in receipt of such services in the course of his normal duties, orb) any employment or other work which is concerned with the provision of care services to vulnerable adults and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to vulnerable adults in receipt of such services in the course of his normal duties One or both of the above apply to work with the Agency, and covers all occupations. You are therefore requested to provide details of all convictions, including those which would otherwise be considered as “spent”. All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected. A) Do you have any Criminal Conviction(s) Yes No B) If yes to question A above, Please provide details below of the Criminal Conviction(s), including the dates of the conviction(s). 9. Supporting Statement Please provide a supporting statement detailing why you are suitable for the position applied. 10. Bank Details for Payroll Purposes Please provide us with the following information as soon as possible to ensure prompt payment Bank Name / Building Society Account Name Account Number Sort Code
