1 Nurse Next Door Application Form

Application Form
PLEASE COMPLETE ALL SECTIONS
Title*
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Nationality*
National Insurance Number (NI Number)*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code

Academic Qualifications*

Rows	Institute / Location of Study	Qualification	Date from & to MM/YYYY
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Qualification Notes
Use this space for additional qualiications

Professional Qualifications*

Rows	Institute / Location of Study	Qualification	Date from & to MM/YYYY
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Qualification Notes
Use this space for additional qualiications
Note: Please bring with your original certificates of all relevant qualifications and certificates you have obtained.

Employment Information
Name and contact details of current employer*
Name, address and contact details

FULL Employment History – please include and detail any gaps*

Rows	Company Name	Position Held	Start Date MM/YYYY	End Date MM/YYYY	Reason for Leaving
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Employment Notes
Please use this space for additional employment

Permissions to Work in the UK
YesNo
YesNo
Professional References
Please provide full names and addresses of two professional employment referees covering between 5-10 years employment history and one character referee. Your first reference must be from your current or previous last place of work and addressed to your line manager. Nurse Next Door cannot use friends or relatives for any employment references. Employment references cannot be sent to private or personal home addresses. You must provide workplace addresses and the referee must be a higher grade of staff than yourself i.e. your line manage. If you do not have two professional referees please provide one professional and two character references.

Professional Reference 1 (Please provide ALL 3 references)
Name*

First NameLast Name
How Do You Know This Person?*
Company*
Job Title*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Email*
example@example.com
Phone Number*

Area CodePhone Number

Character Reference 1 (Please provide ALL 3 references)
Name*

First NameLast Name
How Do You Know This Person?*
How Long Have You Known This Person?*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Email*
example@example.com
Phone Number*

Area CodePhone Number

Professional / Character Reference 2 (Please state which and character cannot be a family member) (Please provide ALL 3 references)
ProfessionalCharachter
Name*

First NameLast Name
How Do You Know This Person*
Company
Job Title (if applicable)
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number*

Area CodePhone Number
Email*
example@example.com

Personal Details: (for Disclosure and Barring Service and employment purposes)
Name at Birth*

First NameLast Name
Other Names: e.g. maiden name. Enter N/A if not applicable*
Date that Maiden Name was used from

MonthDayYear
Date
Date that Maiden Name was used to

MonthDayYear
Date
Town / City of Birth:*
District of Birth:*
Country of Birth:*
Date of Birth:*
Date of Birth:*

DayMonthYear
Date

Full 5 Year Address History

(for Disclosure and Barring Service and employment purposes)

Full 5 Year Address History – please make there are no gaps *

Rows	Address (starting with current and most recent address)	Move In Date MM/YYYY	Move Out Date MM/YYYY
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2
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Disclosure & Barring Services Check
YesNo
If yes please give details:
YesNo
This employment is not exempt from the provisions of the rehabilitation of young offenders Act 1974, you are not therefore entitled to withhold information requested by the company about any previous convictions in this country or abroad you may have, even if in other circumstances these would appear spent. I confirm that the information I have given is true. I understand that if information given on the application form is found to be false it may result in disciplinary action which could include dismissal. Should I be offered employment, I accept that I will be required to notify the company of any changes to my DBS status.
Confidentiality

If you are successful in your application for employment with Nurse Next Door: All information you see or hear in the course of your duty is confidential. You must not disclose any personal details or information relating to clients, their medical conditions or information which is deemed to be commercially sensitive to the organisation.

Employment with Nurse Next Door
It is Nurse Next Door policy to employ the most suitably qualified personnel and to ensure equal opportunity for the advancement of employee. This includes promotion and training and to prohibit discrimination against any individual on the basis of race, colour, ethnicity, nationality, sexual orientation, gender, religion, belief, pregnancy, marital or civil partnership status, age or disability. In completion of this application form, I authorise Nurse Next Door to obtain references to support this application once an offer has been made and accepted. I release Nurse Next Door and submitted referees from any liability caused by giving and receiving any information. I confirm that the information given on this form is to the best of my knowledge, true and complete and that the provision of any false statement(s) will be sufficient cause for rejection or if employed, dismissal.

By signing this application form you have confirmed that you have read, understood and accepted all of the above.
Signature*

Clear
Date*

DayMonthYear
Date
How did you hear about Nurse Next Door? Please provide detail*

Health Assessment

Vaccinations
CoronavirusRubella (German Measles)TetanusFluHepatitis BCertificate of vaccination (hepatitis B)None of the aboveTuberculosis BCG
It may be a requirement of any assignment that you have certain vaccinations depending on government guidelines at the time of application.
I certify that I believe that I am fit for work.*

Clear
Date*

DayMonthYear
Date

Working Time Regulations 1998

The European Union has laid down guidelines for all workers, governing the length of the maximum working week that is safe to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered, you will not be compelled to work more than 48 hours per week, however you may choose to do so.

1) DEFINITIONS

1.1) In this agreement the following definitions apply:

“Employer” Means Nurse Next Door of 2 & 4 Tudor Court, Brighton Road, Sutton, SM2 5AE

“Employee” Means

“Working Week” Means an average of 48 hours each week calculated over a 17 week reference period.

1.2) References to the singular include the plural and references to the masculine include the feminine and vice versa.

1.3) The headings contained in this Agreement are for convenience only and do not affect their interpretation.

2) RESTRICTION

2.1) The Working Time Regulations 1998 provide that the Employee shall not work in excess of the Working Week unless he agrees in writing that this limit should not apply.

3) CONSENT

3.1) The Employee hereby agrees that the Working Week limit shall not apply

4) WITHDRAWAL OF CONSENT

4.1) The Employee may end this Agreement by giving (specify period) notice in writing

4.2) For the avoidance of doubt, any notice bringing this Agreement to an end shall not be construed as notice of termination by the Employee.

4.3) Upon the expiry of the notice period set out in clause 4.1 the Working Week limit shall apply with immediate effect.

5) THE LAW

5.1) These Terms are governed by the law of England & Wales and are subject to the exclusive jurisdiction of the courts of England & Wales.
I DO wish to work more than 48 hrs per weekI DO NOT wish to work more than 48 hrs per week
Signature*

Clear
Date*

DayMonthYear
Date

GDPR
Data Protection

As an employment business our job is to find work seekers (you for example) and match them with roles our clients have. To do this, we engage with various clients & suppliers including but not limited too – Care Homes, Nursing Homes, Hospitals, supported living homes, Umbrella Companies. For us to be successful and assist finding work for you we will need your consent to formally act on your behalf which can involve us sending your information (in the form of candidate profile) to clients/suppliers. In order to do this we need your consent to send this information.

The consent is below and before agreeing to it we would like to make the following points:

You do not have to consent.

If you would like to consent, you must (in addition to ticking the box) sign, print your name and insert the date where indicated.

You can withdraw your consent at any time.

We will only send your personal information for the reasons stated in this document.

We will not send any Special Categories of Personal Data (this is particularly sensitive information).

The umbrella company supplier will use the information we send them only to contact you to discuss how they can engage with you.

The Data Protection Policy can be found on their website. www.kareplus.co.uk
That my personal data be transferred to Nurse Next Door and their associated companies.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Application Form

PLEASE COMPLETE ALL SECTIONS

Employment Information

Permissions to Work in the UK

Professional References

Professional Reference 1 (Please provide ALL 3 references)

Character Reference 1 (Please provide ALL 3 references)

Professional / Character Reference 2 (Please state which and character cannot be a family member) (Please provide ALL 3 references)

Personal Details: (for Disclosure and Barring Service and employment purposes)

Full 5 Year Address History

Disclosure & Barring Services Check

Employment with Nurse Next Door

Health Assessment

GDPR