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APPLICATION FORM

Please complete this form legibly and return it as soon as possible. ONLY INFORMATION PROVIDED ON THIS APPLICATION FORM WILL BE CONSIDERED. Curriculum vitae will also be accepted if attached to the completed form. All information given will be treated with the strictest confidence. Continuation sheets may be added if necessary.

  • 1. PERSONAL DETAILS
  • 2. REHABILITATION OF OFFENDERS ACT
  • 3. ELIGIBILITY TO WORK
  • 5. QUALIFICATIONS
  • 8. TRAINING

Your Details

POSITION APPLIED FOR:

NMC PIN (Nurses ONLY):

PIN EXPIRY:

Full Name

Phone Number

Email:

Gender:

Postal Address:

Post Code

Nationality:

NI Number:

Do you hold a full UK driving license?

Any Endorsements?

Next of Kin:

Next of Kin Full Name:

Telephone number:

Email:

Address:

Relationship to you:

-

Do you have any criminal convictions?

Do you have any pending prosecutions?

If Yes, please give details

Date of offence:

ABOUT YOU

Are you British?

Are you a EU National?

Others: (Resident Permit / Student Visa / Leave to Remain etc) Please specify

4. ADDRESSES IN THE LAST FIVE (5) YEARS

Address 1:

From

To

Address 2:

From

To

Address 3:

From

To

YOUR QUALIFICATIONS

List all qualifications and dates.

6. MEMBERSHIP OF PROFESSIONAL BODIES

7. EMPLOYMENT HISTORY (Please list chronologically, starting with current or last employer)

TRAINING DETAILS

Details of training courses attended and awards achieved, if appropriate:

9. REFERENCES

1st Reference (Full Name)

Address:

Their Position:

E-mail:

Telephone No.:

Relationship to you:

2nd Reference

Reference (Full Name)

Address:

Their Position:

E-mail:

Telephone No.:

Relationship to you:

9. VERIFICATION OF INFORMATION

I declare that all information which I have provided is correct. I understand that any false information given may result in a job offer being withdrawn or my employment terminated.

I declare that all information which I have provided is correct. I understand that any false information given may result in a job offer being withdrawn or my employment terminated.

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.