Gibson`s Lodge Nursing Home
Gibson`s Hill
London
SW16 3ES
Tel: 020 8670 4098 Fax: 020 8670 4261
JOB APPLICATION FORM
Position Applied For :
Date of Application:
Personal Details
Name in full……………………………………………………
Title (Dr/Mr/Mrs etc.)……………..
Address………………………………………………………...
Marital Status……………………..
…………………………………………Postcode…………….
D.O.B………………………………
Home Telephone No…………………………………………
Mobile No…………………………
Work Telephone No…………………………………………..
Religion……………………………
Place of Birth…………………………………………………..
Nationality…………………………
Languages……………………………………………………..
Education
School / College
From
To
Qualifications and Grades
Evidence of qualifications will be required, qualified nurses must produce registration / enrolment
certificates prior to employment.
Pin Number……………………………………..
Expiry Date…………………………………
-1-
Employment History
Please complete your full employment or study history, including any periods of
unemployment.
Company
From
To
Position Held
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Responsibilities
Reason for Leaving
HEALTH
Please circle YES or NO as appropriate and give further information when required.
Have you, within the past two years, had any illness or accident,
which caused you to be off work for two weeks or more?
YES
NO
Immunisation History: BCG
Tetanus
Polio
Hepatitis B
Rubella
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Do you have a BCG scar?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
If YES, please give details:
If YES, where is the scar?
Have you ever had an x-ray?
If YES, where and at which hospital?
Have you, within the past year, attended an outpatient’s clinic or had
a course of treatment (medication, therapy etc.) lasting one month or
more?
If YES, please give details:
Do you smoke?
If YES, how many?
Do you drink alcohol?
If YES, how many units per day/week?
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Are you suffering from or have you ever from the following. If YES
please give details:
Fits
YES
NO
Epilepsy
YES
NO
Blackouts
YES
NO
Diabetes
YES
NO
Tuberculosis (TB) or had close contact with anyone suffering from TB
YES
NO
Depressive illness, mental or nervous illness (including Anorexia,
Bulimia or overdose).
YES
NO
Typhoid, Cholera or Hepatitis
YES
NO
Eczema, Psoriasis or Dermatitis
YES
NO
Allergy to any drugs or to handling any substances
YES
NO
Earache or infection, discharge or defect
YES
NO
Colour blindness, chronic eye trouble, eye injury or visual defect not
corrected by glasses or contact lenses
YES
NO
Tonsillitis, Sinusitis, frequent sore throats or colds
YES
NO
Heart/circulatory disease, high or low blood pressure
YES
NO
Asthma, Bronchitis or Pleurisy
YES
NO
Bowel disorders, recurring diarrhoea or constipation
YES
NO
Bladder or kidney problems
YES
NO
Varicose Veins
YES
NO
Next of Kin
Full Name………………………………………………………
Telephone No…………………….
Address…………………………………………………………
……………………………………..
…………………………………………Postcode…………….
Mobile No…………………………
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References
Please give the full name, address and telephone numbers of at least two referees, who must be
resident in the UK (the first must be your present or most recent employer).
Your application cannot be considered unless you complete all the details requested
below.
First Reference – current or most recent employer
Company
Name
Job Title
Address
Postcode
Telephone No.
Relationship
Second Reference
Name
Address
Postcode
Telephone No.
Relationship
Third Reference (Optional)
You may, if you wish, provide details of a third Referee in case we have problems contacting
your second Referee.
Name
Address
Postcode
Telephone No.
Relationship
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DECLARATION
REHABILITATION OF OFFENDERS ACT 1974
By reason of the nature of the work for which you are applying, the post is exempt from the
provision of Section (42) of the Rehabilitation of Offenders Act 1974 by virtue of the
Rehabilitation of Offenders Act (Exceptions Order) 1975.
Applicants are therefore not entitled to withhold information about convictions, which for other
purposes are spent under the provision of the Act. You must, therefore, disclose information
about all your convictions (if any) no matter when they occurred.
Failure to disclose the information asked for below will result in instant dismissal and / or
disciplinary action. Furthermore, you should also be aware that making a false declaration could
constitute the Criminal Offence of obtaining / attempting to obtain pecuniary advantage by
deception. In such an event, the facts will be reported to the Police.
Section 89(5) of the Care Standards Act (2000) provides that an individual who is included
(otherwise than provisionally) in the list kept by the Department of Health of individuals who are
considered to be unsuitable to work with vulnerable adults (the POVA list) shall be guilty of an
Offence if he / she knowingly applies for, offers to do, accepts or does any work in a care
position.
Any information given will be completely confidential and will be considered only in relation to an
application for positions covered by the Rehabilitation of Offenders Act (Exceptions Order) 1975.
Use the space below to give details of all convictions (if any) or enter “NONE” if you do not
have any (continue on a separate sheet if necessary):
Use the space below to give details of all Police Cautions received (if any) or enter “NONE” if
you do not have any (continue on a separate sheet if necessary):
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Current Work Permit
Expiry Date:
Current Passport
Expiry Date:
National Insurance Number
P45/46
Are you on the POVA List (see above)?
YES
NO
Has a Criminal Records Bureau (CRB) check been carried out
on you for your current job?
YES
NO
I hereby certify the accuracy of all information provided above and understand that failure
to disclose any information or the disclosure of inaccurate or incomplete information may
lead to action being taken as detailed above.
Signed: _______________________________________________Date: __________________
Name: ______________________________________________
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For Official Use Only:
Outcome of Interview:
Position Applied For:
Pin Checked:
Reference 1 applied for on:
Reference 2 applied for on:
Police check applied for:
Copy of Passport:
Copy of Work Permit:
National Insurance Number:
P45 P46 received:
Contract given:
List 99 checked:
Bank/building society:
Account No:
Bank/Building Society details
Account Name:
Sort Code:
-8-