Application Form
*Full Name
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
What position are you applying for?
*
Community Care Worker
Respite Sitter
Health Care Assistant (Agency)
Registered Nurse (Agency)
Registered Nurse - Enhanced Care at Home
This position requires an ACCESS NI application, which will include a check of the barred lists for adults and children. Do you consent?
*
Yes
No
Do you have your own transport?
*
Yes
No
NISCC/NMC Number
*
Next of Kin Details
*
National Insurance Number
*
Date of Birth
*
Driving Licence Number
*
What is your current employment status
*
Employed
Unemployed
Self- Employed
Student
Full Employment History (from age 18 to present) Please include name of employer, dates of employment(dd/mm/yy), reason for leaving each role and do this for each position
*
For Example
Have you ever been convicted of a criminal offence?
*
Yes
No
If you selected yes, add details. PLEASE NOTE A CRIMINAL RECORD DOES NOT MEAN YOU CANNOT BE EMPLOYED
*
You have the right to opt out of the 48 hour working week limitation, as laid down in the working time regulations 1998
*
I do not wish to work more than 48 hours per week
I do wish to work more than 48 hours per week
Please provide details for 2 employment references, one of which must be from your MOST RECENT employer. If you are unable to provide 2 employment references, you must still include details of your MOST RECENT employer, along with 2 character references from nursing or care colleagues.
*
Signature
*
Submit
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