APPLICATION FORM
- 1. Please complete all sections fully incomplete forms will be returned NISE NURSING LIMITED Please attach a passport size photograph and clearly print your name on the reverse of each Please attach a passport size photograph and clearly print your name on the reverse of each 1.0 Your Personal Details: Surname:_ Forename: Previous names: Title: (Inc maiden name) Dates when you used Previous Names Contact Details: Current address: County: Post code: At this Address Since_ Home Tel: Mobile: Other: Email: Date of Birth: Nationality (at Birth): Town of B i rt h: ______________________ Nationality (at present): _ Passport No: Date of Issue: Place of issue: Date of expiry: Visa: Yes / No/NA Residency status if not UK or EU citizen Date of expiry: Marital status: Position applied for: N I number: Who should we contact in an emergency? Surname:_ First name:_ Relationship:_ Tel number 1: Tel number 2: Next of Kin (if different from above): Surname:_ First name:_ Relationship:_ Tel number: Tel number 2:
- 2. NISE NURSING LIMITED 1.1 Your Personal Details (cont) All your addressover the pastfive years Previous Address 1 Dates to and from that address Previous Address 2 Dates to and from that address Previous Address 3 Dates to and from that address Previous Address 4 Dates to and from that address Previous Address 5 Dates to and from that address Previous Address 6 Dates to and from that address Previous Address 4 Dates to and from that address
- 3. NISE NURSING LIMITED 1.2 Rehabilitation of Offenders Act By virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) Amendments Order 1986, the provision of section 4.2 of the Rehabilitation of Offenders Act 1974 does not apply to any employment which is concerned with the provision of health services and which is of such a kind as to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties. Your answer to the following questions should include any spent convictions. This may or may not affect your application. All Nurses and Care Staff will be asked to apply for an Enhanced Disclosure with the Criminal Records Bureau as part of the recruitment and selection process. Please include any driving offences as these will appear on an enhanced CRB disclosure form. Have you ever been convicted of a criminal offence? □ Yes □ No If 'Yes', please give details: Date of conviction: Nature of conviction: Please continue on ‘Section 7.0 Your Notes’or on a separate sheet if required Are you currently the subject of criminal proceedings? (eg charges or summons that are not yet being dealt with)? □ Yes □ No If 'Yes', please give details: Date of conviction: Nature of conviction: Please continue on ‘Section 7.0 Have you ever been dismissed from a nursing or care post? □ Yes □ No If 'Yes', please give details: Date of dismissal: Nature of dismissal: Please continue on ‘Section 7.0 Your Notes’ or on a separate sheet if required __ __ Are you currently suspended, on notice of dismissal from employment or under investigation from any employer? □ Yes □ No If 'Yes', please give details: Please continue on ‘Section 7.0 Your Notes’ or on a separate sheet if required 1.3 Miscellaneous Are you currently on maternity leave? □ Yes □ No Do you belong to a union or professional body? Please present your card for copying on interview □ Yes □ No If yes, which: Do you have professional indemnity cover? □ Yes □ No If yes, which type:_
- 4. NISE NURSING LIMITED 1.4 Transport Are you a car owner? Yes / No Do you have a full British Driving License? Yes / No If not, state details: 1.5 Working Time Regulations You have the option to opt out of the 48 hour working week limitation as laid out in the Working Time Regulations 1998. Please indicate one of the following: I wish to opt out □ I do not wish to opt out □ If your circumstances change, please inform the office in writing allowing a 14 day notice period. 2.1 Your Qualifications Please continue on ‘Section 7.0 Your Notes’ or on a separate sheet if required Have you completed any of the following courses? (Please tick): You will need to provide certificates as evidence. MAPA Yes/ No Dates: Managing Challenging Behaviour Yes/ No Dates: ___ Manual Handling Yes/ No Dates: First Aid Yes/ No Dates: NVQ Yes/ No Dates: Food Hygiene Yes/ No Dates: Basic Life Support Yes/ No Dates:_ Health & Safety Yes/ No Dates: 2.2 Other Courses (please specify): Course Date Where taken Certified Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ 2.3 To Be Completed ByRegistered Nurses Only We need to know your qualifications. These are to include details of NMC registration, Post registration qualifications and any other qualifications that you think are relevant. NMC PIN number: Part of register: Expiry: Name of training Hospital or University Date Qualifications
- 5. NISE NURSING LIMITED 3.0 Your Employment History Please provide in date order details of your full employment history including the last full time educational establishment attended, starting with your present or latest position. Employers will not be approached without your permission. Please account for any intervals of non- employment and include temporary jobs and full time service, please continue on a separate sheet if necessary. Name & full address of Employer: Dates: From: To: Type of ward/dept: Salary: Position Held: Reason for leaving: Duties/Responsibilities – Please give FULL DETAILS. Name & full address of Employer: Dates: From: To: Type of ward/dept: Salary: Position Held: Reason for leaving: Duties/Responsibilities – Please give FULL DETAILS. Name & full address of Employer: Dates: From: To: Type of ward/dept: Salary: Position Held: Reason for leaving: Duties/Responsibilities – Please give FULL DETAILS. Name & full address of Employer: Dates: From: To: Type of ward/dept: Salary: Position Held: Reason for leaving: Duties/Responsibilities – Please give FULL DETAILS. Continue on Your notes if necessary.
- 6. NISE NURSING LIMITED Name & full address of Employer: Dates: From: To: Type of ward/dept: Salary: Position Held: Reason for leaving: Duties/Responsibilities – Please give FULL DETAILS. Name & full address of Employer: Dates: From: To: Type of ward/dept: Salary: Position Held: Reason for leaving: Duties/Responsibilities – Please give FULL DETAILS. Name & full address of Employer: Dates: From: To: Type of ward/dept: Salary: Position Held: Reason for leaving: Duties/Responsibilities – Please give FULL DETAILS. Name & full address of Employer: Dates: From: To: Type of ward/dept: Salary: Position Held: Reason for leaving: Duties/Responsibilities – Please give FULL DETAILS. Continue on Your notes if necessary.
- 7. NISE NURSING LIMITED 4.0 Your References Please give the details of at least tw o referees. Additional referees may be supplied on a separate sheet if required Referees must be of a more senior position than yourself and must have known you for a period of no less than 3 years. Only work addresses and e-mail addresses are accepted. ***Please ensure that the people stated will reply to this request as employment is dependent upon receipt of sufficient references.*** Present or most recent employer Clinical referee Full Name: Full Name: Occupation: Occupation: Organisation: Organisation Address Address Tel Number Tel Number Fax Number: Fax Number: Email: Email: Can we fax or email your referees to speed up the registration process? □ Yes □ No Can we approach your referees before the interview? □ Yes □ No 5.1 Notice:Health All applicants are reminded that it is unethical for Health Care Workers who know or believe themselves to be infected with any blood borne viruses (HIV, Hepatitis B or C) or other communicable diseases (e.g. Tuberculoses) to put patients at risk by failing to seek appropriate counselling or by failing to disclose it when notified. Such behaviour may affect your ability to practise within the health or social care industry. 5.2 Health Declaration I certify that I know of any reason why my health would affect my ability to practice within the the health or social care industry I understand that I will be required to obtain a “Fitness to Practice Certificate” via NISE Nursing’s occupational health provider. I understand that no medical details will be disclosed without my permission to any individual other than those necessary and authorised within NISE Nursing Ltd. I understand that failure to disclose information or the giving of false information may prohibit an offer of temporary staffing assignments. Print Name ……………………………. Signature ……………………………… Date ……………………
- 8. NISE NURSING LIMITED 6.0 Your Notes Please include any additional information that may be relevant to your application and has not already been mentioned in any other part of the form; ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... ……………………………………………………………………………………………………………………........................... …………………………………………………………………………………………………………………….......................... 7.0 Declaration I declare that the information I have given in this application form is complete and accurate in all respects. I understand that NISE Nursing Agency needs to process the information that I have provided to them which constitutes personal and sensitive data as defined in the Data Protection Act 1998. I hereby give permission for NISE Nursing Agency to process such data for the purpose of Health and Safety and to other parties as required to assess whether I am suitable for flexible staffing assignments, and for my file to be viewed by authorised third parties for the purpose of audit e.g. The Care Quality Commission or NHS Purchasing Consortia. I also understand that knowingly giving false information will disqualify me from registration with NISE Nursing Agency. Signed: Date: 7.1 What do I do now? Please return to NISE Nursing Limited, 45 Bradgate Street, Leicester LE4 0AW