Nurse/Carer Application Form

Personal Details

Please complete all sections

Formal Education and Qualifications

Please complete all sections

Employment History

Please fill in details of all your employment for a period of at least the last 10 years, to include all nursing agency memberships, in reverse date order; starting with your present or last position. Please include reasons for gaps.

Training

eg. Manual handling, CPR, infection control, first aid etc., (please provide certificates)

Professional Details

General Information

Preference Regarding Work

Immunisation

Proof of immunisations must be provided

References

References are normally taken up for candidates selected for interview. Give details of the names/addresses of two work-related Referees. One of the Referees should be your current employer, or if presently unemployed or self-employed, your last employer

Reference 1

Reference 2

Confidentiality Declaration

Registration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about your clients. On no account must information relating to identifiable client be divulged to anyone other than the manger of the agency. You should not disclose ANY information to your family, friends or neighbours. If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER. Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register. I have read and I understand the above and I agree to abide by the contents therein.

Rehabilitation of Offenders Act

Note:

(To protect the confidentiality of this information, please detail convictions on a separate sheet of paper. Place it in a sealed envelope with your name clearly visible, and headed “Private and Confidential – Criminal Convictions” and attach this to your completed Application Form)

Criminal Records – Disclosure Certificate

The Criminal Records Bureau (CRB) have issued a Code of Practice regarding Disclosure Information, a copy of which is available upon request. A Disclosure Certificate (standard or enhanced) will be requested from the CRB which will detail all convictions, including those which would otherwise be “spent”, as well as details of cautions, reprimands or final warnings. You will be advised of the type of certificate being requested, and asked to give your approval to this application. The Disclosure Certificate will only be requested in the event that you are successful in your application for employment.

Asylum and Immigration Act 1996

Under Section 8 of the Asylum and Immigration Act 1996 it is a criminal offence to employ a person aged 16 or over who is subject to immigration control unless: That person has current and valid permission to be in the United Kingdom and that permission does not prevent him or her from taking the job in question; or The person comes into a category specified by the Home Secretary where such employment is allowed Any employment offered will be subject to the successful applicant producing appropriate evidence that the Asylum and Immigration Act is not being contravened.

Personal Declaration

I declare that to the best of my knowledge the above information, and that submitted in any accompanying documents, is correct, and I give permission for any enquiries that need to be made to confirm such matters as qualifications. experience and dates of employment, and for the release by other people or organisations of such information as may be necessary for that purpose. I give permission for the processing of the personal data contained in this form for employment purposes I understand that any false or misleading information could result in my dismissal.

Equal Opportunities Monitoring Form

Living Spring Healthcare operates a policy of Equal Opportunities: therefore, we need to be able to check that decision are not influences by unfair or unlawful discrimination. To help use to do this we would be grateful if you could complete this short questionnaire. Your answers will be treated with the utmost confidence and will be used only for statistical purposes.