Microsoft word - application form.doc

APPLICATION FOR EMPLOYMENT
Ref. No: ________

POSITION APPLIED FOR: Practice Nurse / Nurse Prescriber (delete as appropriate)

For part-time positions, please give an indication of the minimum and maximum hours per week you
are seeking:

Forename(s)
Address (with postcode):

Email address:
Telephone number:
NMC registration number:

Current driving licence? Yes/No
Details of
endorsements

Are there any restrictions on you taking up employment in the UK? Yes No (If yes, please provide details)


EDUCATION HISTORY

Schools/Colleges/universities/other training institutions Qualifications gained
Professional qualifications/courses Qualifications gained


EMPLOYMENT HISTORY (Please complete in full and use a separate sheet if necessary – MOST RECENT FIRST)
NAME AND ADDRESS
JOB TITLE AND DUTIES
START/FINISH
REASON FOR LEAVING
OF EMPLOYER
NOTICE REQUIR
ED IN CURRENT POST

OTHER EMPLOYMENT
Please note any other employment you would continue with if you were to be successful in obtaining this position. GENERAL COMMENTS
Because we are willing to train the right candidate, we would be grateful if you could let us know
your current skill-level:
Experience of
Qualifications if applicable
(please tick)
Assisting with coil insertion/removal Assisting with contraceptive implants Hypertension/other reviews (pls specify) Please use the space below to explain why you would be a good applicant for the post,
including personal qualities and examples (please continue on a separate page if required).

Please note here your leisure interests, sports and hobbies, other pastimes etc.
REFERENCES
Please note here the names and addresses of two persons from whom the company may obtain both character and work experience references. CRIMINAL RECORD
Please note any criminal convictions except those 'spent' under the Rehabilitation of Offenders Act 1974. If none please state. In certain circumstances employment is dependent upon obtaining a satisfactory basic disclosure from the Criminal Records Bureau/Scottish Criminal Records Office.
APPLICANTS WHO ARE PATIENTS OF THE SURGERY
We consider that employing staff who are patients of the practice has significant disadvantages both to the patient and to
the practice. Please note therefore that if your application is successful, you will be required to register elsewhere
DECLARATION (Please read this carefully before signing this application)
1. I confirm that the above information is complete and correct. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of the application or immediate termination of employment, whenever it may be discovered. 2. I agree that the organisation reserves the right to require me to undergo a medical examination. (Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor). I agree that this information will be retained in my personnel file during employment and for up to six years thereafter and understand that information will be processed in accordance with the Data Protection Act. 3. I agree that should I be successful in this application, I will, if required, apply to the Criminal Records Bureau for a basic disclosure. I understand that should I fail to do so, or should the disclosure not be to the satisfaction of the practice any offer of employment may be withdrawn or my employment terminated. Signed: …………………………………………………. Date: ……………………………………….
DIVERSITY MONITORING INFORMATION

This practice is an equal opportunities employer and does not unlawfully discriminate in employment.
No information provided by the applicant will be used for the purpose of limiting or excluding any
applicant from consideration for employment on a basis prohibited by law.
Please tick the box which best describes your cultural & ethnic origin
□ White British
FOR OFFICE USE ONLY

Source: http://www.thesurgeryashbourne.co.uk/website/C81086/files/Application_form.pdf