Nurse Sign Up Form

Next of Kin
This information will only be used in emergency, e.g. if you don't turn up to a shift and we're unable to reach you after multiple attempts.
Full Name*

First NameLast Name
Relationship & Contact number*

Next of Kin relationship to youNext of kin contact Number

Employment History (Skip this section if you have already sent us your CV via indeed or email)
Please add your employment history below. Explain any gaps of more than three months.
Explain any Gaps of more than three months below:

Your Professional References
You must provide references from your two most recent employers. The email you submit will be used to obtain a reference in the first instance. Both will be contacted, therefore please inform the referees of the fact that you have used their name. Please provide details of 2 referees from people you have previously worked with in a nursing or care role

We accept references from :
- Any previous nursing or care employer
- A band 5 nurse, Clinical Lead, or higher
- Up to one nursing or agency manager
Current / Most Recent Employer

Referee 1
Referee 1 Full Name*

First NameLast Name
Position/Organisation*

Referee Job TitleOrganisation Name
Referee 1 Email Address*
example@example.com
Referee 1 Phone Number*
Enter Referee 1 phone number
Previous Employer (to the one above)
Referee 2 Full Name*

First NameLast Name
Position/Organisation*

Referee Job TitleOrganisation Name
Referee 2 Email Address*
example@example.com
Referee 2 Phone Number*
Enter Referee 2 phone number