Nurse Application Form

Employment History

Please Give Details Of Your Past 5 Years Of Continuous Work History Giving Reasons/s For Any Breaks In Employment.
1. Employer
1. From

MonthDayYear
Date
1. To

MonthDayYear
Date
1. Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
1. Phone Number

Area CodePhone Number
1. Main Contact
1. Post title
1. Grade
1. Type of employment
1. Salary
1. Main Responsibilities
1. Department/ Ward
1. Reasons for leaving
2. Employer
2. From

MonthDayYear
Date
2. To

MonthDayYear
Date
2. Address

Street Address

Street Address Line 2

CityCounty

Postcode
2. Phone Number

Area CodePhone Number
2. Main Contact
2. Post title
2. Grade
2. Type of employment
2. Salary
2. Main Responsibilities
2. Department/ Ward
2. Reasons for leaving
3. Employer
3. From

MonthDayYear
Date
3. To

MonthDayYear
Date
3. Address

Street Address

Street Address Line 2

CityCounty

Postcode
3. Phone Number

Area CodePhone Number
3. Main Contact
3. Post title
3. Grade
3. Type of employment
3. Salary
3. Main Responsibilities
3. Department/ Ward
3. Reasons for leaving

Rehabilitation of offenders act 1974
Because of the nature of the work for which you are applying, this post is exempt from the provisions of section 4.2 Rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are therefore, not entitled to withhold information about convictions, which for other purposes are 'spent' under the provision of the Act in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Information provided will be kept confidential and use in relationship to the post applied for.
Have You Ever Been Convicted Of A Criminal Offence?

YesNo
Please specify details of your criminal offence
Do You Have Any Spent Or Unspent Convictions?

YesNo
Please specify details of your Unspent Convictions?
Have You Instigated An Enhanced Disclosure Within The Last Six Years?

YesNo
I Consent To Perfect Quality Care Checking The Details I Have Provided Against The Various Data Sources In Order To Verify My Identity And Process This Application. These Details Maybe Use To Assist Other Organisation Such As DBS CHECKS, in Identity Purposes.

References

Please Give The Names And Addresses Of Two Of Your Most Recent Employers With Work Addresses Who are Able To Comment On Your Work Ability And Experience. Starting With Your Present To Most Recent Employer If Possible.
A. Name of reference

First NameLast Name
A. Company's name
A. Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
A. Phone Number

Area CodePhone Number
A. Email address
example@example.com
A. Mobile Number

Area CodePhone Number
A. From

MonthDayYear
Date
A. To

MonthDayYear
Date
B. Name of reference

First NameLast Name
B. Company's name
B. Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
B. Phone Number

Area CodePhone Number
B. Email address
example@example.com
B. Mobile Number

Area CodePhone Number
B. From

MonthDayYear
Date
B. To

MonthDayYear
Date

Building Society/ Bank details
Bank Name:
Bank Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Building Society Bank Roll
Account Holder's Name
Sort-Code
Account number
By ticking this I authorise Perfect Quality Care to pay my weekly wages into the above Bank Account and I will notify Perfect Quality Care if changes occur to my details.

Working Time Regulations
According To The Working Time Regulations
- You are not required to work more than 48 hours per week except agreed in writing.
- An Agency staff is entitled to 11 hours rest from work in each 24 hours and 12 hours if under 18 years.
- A minimum of 20 minutes break when the working day is longer than 6 hours.
- Staff should not work 8 hours in every 24 hours if it is night work.
- Staff is entitled to a minimum of 1 day rest from work each week or 2 days every 2 weeks.
- Staff is entitled to 4 weeks paid annual leave once they have worked through a particular agency for a continuous 13 weeks period.
I have read and understood the Working Time Regulations and I hereby consent that the working time limit shall not apply to my assignments.
Date of agreement

DayMonthYear
Date

Final Statement
I Declare That The Information Provided On This Application Is True To The Best Of My Knowledge. I Have Read The Terms And Condition Of Engagement And Agree To Comply With The Current Health And Safety At Work Act. I Understand That My Appointment Is Subject To The Receipt Of Two Satisfactory References And It Subject To Enhanced DBS Disclosure. Perfect Quality Care Is Free To Make Any Other Enquiries They May Find Necessary Relating To My Application. I Agree To Respect The Confidentiality Of Patients And Clients And Any Other Information I May Have Access To.
Date of agreement

DayMonthYear
Date

Check list		Check	Notes
Application
Proof od Address	Utility bills, bank statements, others.
Prood of identity	Passport, driving license others
Eligibility to work	Visa, Work Permit, passport, birth certificate
NMC Pin Number
48 hours apt out
DBS/ CRB Application
PAYE Form
2 passport photograph
Immunisation
Signed contract

AGENCY SIGN OFF
I Certify that I interviewed the above applicant in accordance with the Perfect Quality Care requirements and I am satisfied that this applicant is cleared for work.
Name of Consultant
Date
Should be Empty:

MID WIVES ONLY