Application Form 1( NURSES)
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APPLICATION FORM 1 Please complete as appropriate in BLOCK CAPITALS PERSONAL DETAILS POSITION APPLYING FOR:……………………………………………………………….. Mr/Mrs/Miss/Ms:..............Surname:............................................................................................ Forenames: …………………………………............................................................................ Marital Status: …………………......Maiden Names: …………………………………………. Date of birth (dd/mth/yr)............................................................Male Female Religion……………………………………Ethnic Origin…………………………………….. Address:........................................................................................................................................ ...................................................................................................................................................... Postcode........................................................Country.................................................................. Home Tel No ...............................................Mobile No.............................................................. Email address............................................................................ National Insurance No............................................................... NEXT OF KIN Full Name..............................................................Relationship................................................ Tel No: .................................................... Address: ………...................................................... ………………………………………………………………………………………………… …………………………………………………………………………………………..…….. Email:………………………………………………………………………………………….. Providing Quality Motivated Flexible Workforce ADDITIONAL INFORMATION Nationality……………………………Passport/UK Birth Certificate No…..……………….. Do you hold a British WORK PERMIT? Yes If yes, Work Permit Type or No Expiration Date: Name of college/university (if student) Studying? If yes when do you graduate? Are you undergoing Adaptation? If yes completion dates: Have your own transport? Type of Transport? Have you a driving license? If yes any endorsement? Children under 18 years? Ages Do you smoke? Yes Registered Disabled? Yes No or No Registration No: I give my permission for GENETICARE LIMITED to run a Right to Work check with the Home Office for my Right to work in the UK. Signed: .................................................................Date: ........................................................ QUALIFICATION Professional Body EDUCATION/QUALIFICATION PLACE FROM TO (Month/Year) (Month/Year) PROFESSIONAL QUALIFICATIONS & TRAINING Registration Expiry Date Number Providing Quality Motivated Flexible Workforce Date of Application Date of last Basic Life Support training:..................................................................................... Date of last Moving and Handling training:................................................................................ Date of last Health and Safety training:...................................................................................... Please provide documentary evidence of all of the above; all certificates will be verified. MIDWIVES ONLY Midwives please circle the appropriate box if practising Yes No Intention to practice completed?: Yes No Expiration Date / / EMPLOYMENT HISTORY Please list most recent employer and provide us with 10 years work history, accounting for any gaps in employment of over one month. If necessary to do so, please continue on a separate sheet. Employment 1: Start Date;:………………………Leaving Date:…………………….. Name & Address of Employer: ……………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………….…… Specialty, Grade/Position……………………………………………………………………… Employment 2: Start Date;:…………………Leaving Date:………………..…… Name & Address of Employer: ……………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………….…… Specialty, Grade/Position……………………………………………………………………… Providing Quality Motivated Flexible Workforce Employment 3: Start Date;:…………………Leaving Date:……………………..…… Name & Address of Employer: ……………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………….…… Specialty, Grade/Position……………………………………………………………………… NOTE: Please use additional sheet, if required. We strongly advise you to have your own Professional Indemnity insurance. Do you already have this in place? Yes or No If yes, please state: Where Obtained:…………………………………………………………….………………… Registration Date:……………………………………Expiration Date:…….………………… If no, we strongly advise that you contact a suitable organisation to arrange the relevant cover. HEALTH DECLARATION Have you been vaccinated or tested against the YES following? Hepatitis B HIV Tetanus Poliomyelitis Typhoid Rubella (German Measles) Tuberculosis and BCG Hepatitis B Antibodies Mantoux, test or Heaf Varicella Last X-ray Others (Specify) Do you or have you at any time suffered from YES any of the following? NO DETAILS (Plus dates if YES) NO Details. (required if YES) Providing Quality Motivated Flexible Workforce Skin complaints- dermatitis, Psoriasis, Eczema Diabetes or glandular complaints Headaches or Migraine Hypertension/ heart problems/ similar illness Back pains / Back injury or problems Jaundice / Hepatitis Epilepsy or fainting attacks Pleurisy /Bronchitis / Pneumonia Asthma Infections - ear / sore throat Psychiatric illness – Mental disorder/ depression etc At present are you having any YES injections/medications Are you under any treatment of any kind of YES condition? Have you had any major operations Physical Disabilities? How much time have you taken off work in the last 5 years due to illness?. Please state any other information about your health which may affect your work NO Details (if YES) If you do not have vaccination information, please provide details of where we can request them below. I certify the above information is correct and hereby give permission to Geneticare Limited to request a further report from my GP/ Occupational Health/ Hospital for clarification if required and for my health report. GP/Occupational Health/Hospital……………………………………………………………… Address………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Telephone………………………...………Mobile:……………………………………………. Email:…………………………………………………………………………………………... Applicant’s Signature:…………………………………………Date:………………………… Providing Quality Motivated Flexible Workforce REHABILITATION OF OFFENDERS ACT 1974. Have you ever been convicted of a criminal offence? Yes No If yes, Please specify:…………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… …………………………………………………………………...………………………………………………….. Do you have any spent or unspent conviction? Yes No If so, please specify:……………………………………………………………….………….. ………………………………………………………………………………………………… ………………………………………………………………………….……………………… Have you instigated an enhanced disclosure within the last six years? Yes No I consent to GENETICARE LIMITED checking the details i have provided against the various data sources in order to verify my identity and process this application. These details may be used to assist other organisation such as CRB, and in identity purposes. Signature………………………………………Date…………………………..……….. . REFEREES Please give the names and contact details of the minimum of two professional referees from your current/previous employment (covering at least 3 years). Referees must have worked in a senior position to you. Please be aware that we are unable to offer you work until satisfactory references have been obtained. 1. Organisation:…………………………………………………………………………. Date Employed:…………………………Leaving Date:……………………………… Name of Referee:……………………………………………………………………… Referee’s Position:…………………………………………………………………….. Work Address:………………………………………………………………………… ……………………………………………………………………………………….. ………………………………………………………………………………………. Telephone………………………………. Fax: …………………………………… Providing Quality Motivated Flexible Workforce Email:………………………………………………………………………………..... 2. Organisation:…………………………………………………………………………. Date Employed:…………………………Leaving Date:……………………………… Name of Referee:……………………………………………………………………… Referee’s Position:…………………………………………………………………….. Work Address:………………………………………………………………………… ……………………………………………………………………………………….. ……………………………………………………………………………….………. Telephone………………………………. Fax: …………………………………… Email:………………………………………………………………………………..... 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 CRB Disclosure. Geneticare Limited is free to make any other enquiries thy 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. Signed Date Providing Quality Motivated Flexible Workforce
