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1. Personal Details

Data Protection Statement

The personal information (data) collected on this form, and on the attachments, (which includes the collection of sensitive personal data) are collected for the purposes of recruitment, personnel administration (for new employees) and monitoring. Unless you direct otherwise (for example in a situation where you would like this Application kept on file for future vacancies) the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6 months. It is the policy of the Agency to protect, and keep secure, all personal data collected. All personal data is processed for the purposes of recruitment, and, in the case of successful Applicants, for the satisfactory administration of their employment, and for no other purpose.

Which of the following applies to you?
Registered Nurse
Healthcare assistant
Support Worker


Current Address









If less than 5 years at current address please state previous addresses below including time spent there.

Previous addresses

Next of Kin

Person to be notified in case of emergency




2. Eligibility To Work

Please tick appropriately:

Do you hold a British Passport?
Are you a member of the EU?

3. Formal Education and Qualifications

Course of Study/Qualification(s) gained and year e.g. GCSE’s (2014), “A” levels (2014), NVQ (2014), Degree (2014) etc






4. Employment History

Please type details of all your employment for a period of at least the last 5 years, to include all nursing agency memberships, starting with most present employment. Please include reasons for gaps.

5. Mandatory Certificates

Please select below:

Health & safety
Fire Safety
Infection control
Manual handling
Safeguarding Vulnerable Adults
Lone Worker

6. Immunisations

You will be asked to proof of immunisation

Rubella
Skin Test for TB
BCG
Tetanus
Varicella (Chickenpox/Vz.Abs)
Poliomyelitis
Diptheria
Hepatitis B

7. References

Please supply the names of TWO referees. One of the references MUST be a professional referee.

First Reference






Second Reference







8. Rehabilitation of Offenders Act

As a general rule, no-one need answer questions about spent convictions. However this general rule does not apply to specified professions, employments and occupations. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to:

a) any employment or other work which is concerned with the provision of health services and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to persons in receipt of such services in the course of his normal duties, or
b) any employment or other work which is concerned with the provision of care services to vulnerable adults and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to vulnerable adults in receipt of such services in the course of his normal duties

One or both of the above apply to work with the Agency, and covers all occupations.

You are therefore requested to provide details of all convictions, including those which would otherwise be considered as “spent”. All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected.

A) Do you have any Criminal Conviction(s) Yes No 

B) If yes to question A above, Please provide details below of the Criminal Conviction(s), including the dates of the conviction(s).

9. Supporting Statement