Staff Nursing Application

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Please select what post you are applying for*
Surname*
Previous Surname(s)*
Forenames in full*

Address
House Number and Street*
Town*
Post Code*

Contact Details
Main Number*
Mobile Number*
Email*
National Insurance Number*
Date of Birth*

Emergency Contact Details
Name*
Relationship*
Contact Numbers*

How did you hear about us?
How did you first hear about Staff Nursing?*

Social MediaRecommendationIndeedI was registered beforeOther
Other:*
Please specify – Facebook/Twitter/LinkedIn/Instagram*
By whom?*

Visa / Work Permit
Are you a British or EEA citizen or spouse of British or EEA citizen? *

YesNo
If the answer is no please complete the section below.
Do you have a UK Residence Permit?*

YesNo
Are they any restrictions?*

NoYes

Professional Bodies & Indemnity
NMC / NISCC Number*
Have you ever been involved in any disciplinary or dismissal proceedings with an employer?*

NoYes
Are you presently under investigation by the NMC or NISCC?*

NoYes
Have you ever been investigated in your job role in the past?*

NoYes
Do you have any cautions with the NMC or NISCC?*

NoYes

Rehabilitation of Offenders act 1974
By virtue of the Rehabilitation Act 1975 (Exemptions) Order 1975, the provisions of Sections 4.2 of the Rehabilitation of Offenders Act 1974 do 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.

It is therefore not contrary to the act for referees to state any criminal convictions that would otherwise be considered as spent.

Please note Policy 0813/63 (Recruitment and Employment of Ex-Offenders) – copy available on request
Do you have any convictions or cautions? *

NoYes
If you answered yes to the above question please give details*
Are you currently the subject of any criminal proceedings or any police investigation?*

NoYes
If you answered yes to the above question please give details*
Access NI operates under the provisions of Part V of the Police Act 1997. All healthcare workers will be asked to apply for an Access NI Enhanced Disclosure as part of the recruitment and selection process. The cost of this is £32 and is the responsibility of the applicant. Any additional information relevant after the commencement of employment must correspond to Staff Nursing. The ACCESS NI CODE of PRACTICE (May 2018) has been made available to me by clicking the link below:

Access NI code of practice

Staff Nursing has policies on the Recruitment of Ex-Offenders and the Secure Use, Handling, Storage, Retention, and Disposal of Information. Both are available on request. A criminal record is not a bar to employment and may not exclude you from being offered membership with Staff Nursing.
Is there any reason why you cannot work in regulated activity? (Exempted Question) *

NoYes
By submitting you agree to the AccessNI statement above**

I agree

Education
University/College*
Date attended - from*
Date attended - to*
Degree/Diploma obtained*

Employment history
Please complete details of ALL your employment history in chronological order, starting with your present. (Any gaps in employment must also be listed, and reasons why noted)
Employer 1
Employer*
Address*

Address Line 1

Address Line 2

CityCounty/Region

Postcode
Position held*
Date from*
Date to*
Reason for leaving*

Employment history
Employer 2
Employer*
Address*

Address Line 1

Address Line 2

CityCounty/Region

Postcode
Position held*
Date from*
Date to*
Reason for leaving*

Employment history
Employer 3
Employer*
Address*

Address Line 1

Address Line 2

CityCounty/Region

Postcode
Position held*
Date from*
Date to*
Reason for leaving*

Additional Employment History
Please upload your CV or send details of further employment history*

Cancelof

References
Reference/Referee details – one must be your current or most recent employer
Reference 1
Can we contact before interview*

YesNo
Name*
Position/job title*
Address*

Address Line 1

Address Line 2

CityCounty/Region

Postcode
Contact number*
Email*

References
Reference 2
Can we contact before interview*

YesNo
Name*
Position/job title*
Address*

Address Line 1

Address Line 2

CityCounty/Region

Postcode
Contact number*
Email*

Submission
By submitting this application, you consent to Staff Nursing holding your information for 18 months, we may consider you for suitable positions including different areas should they become available. You have the right to consent or object to this.
Do you understand and agree?*

I agree
Should be Empty:

Apply Now

Address

Contact Details

Emergency Contact Details

How did you hear about us?

Visa / Work Permit

Professional Bodies & Indemnity

Rehabilitation of Offenders act 1974

Education

Employment history

Employer 1

Employment history

Employer 2

Employment history

Employer 3

Additional Employment History

References

Reference 1

References

Reference 2

Submission