Test Application Form - Please complete complete all sections RM_Stats1. Personal DetailsTitleName *Last Name *Address House #, Street Name * City, Town, County, * Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and the McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iraq Iran Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Republic Of Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country * Post Code Email Address *Telephone *Mobile *National Insurance #NationalityRight to Work in UKNext of Kin to be notified in case of emergency: NameAddress House #, Street Name City, Town, County, Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and the McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iraq Iran Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Republic Of Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Post Code RelationshipTelephoneMobile2. Educational QualificationsDates (From:To)Name of InstitutionCourse TakenGradeDates (From:To)Name of InstitutionCourse TakenGradeDates (From:To)Name of InstitutionCourse TakenGradeDates (From:To)Name of InstitutionCourse TakenGradeDates (From:To)Name of InstitutionCourse TakenGrade3. Employment HistoryStart with the most recent an cover at least 10yearsDates (From:To)Employer & AddressPosition & DutiesReason for leavingDates (From:To)Employer & AddressPosition & DutiesReason for leavingDates (From:To)Employer & AddressPosition & DutiesReason for leavingDates (From:To)Employer & AddressPosition & DutiesReason for leavingDates (From:To)Employer & AddressPosition & DutiesReason for leaving4. Traininge.g. Manual handling, CPR, infection control, first aid etc., (please provide certificates)Dates (From:To)Trainer/ProviderCourse TakenAttainmentDates (From:To)Trainer/ProviderCourse TakenAttainmentDates (From:To)Trainer/ProviderCourse TakenAttainmentDates (From:To)Trainer/ProviderCourse TakenAttainmentDates (From:To)Trainer/ProviderCourse TakenAttainment5. Professional DetailsSPECIALITY AND YEARS EXPERIENCEThe service we give depends on accurate up to date information. Please keep us informed of all developments in your career. To assist us in finding suitable work for you, please list all nursing specialties and number of years experience you have significant, post training experience. e.g A&E - 2years, practice nursing - 5years etcSpeciality and years experiencePROFICIENCY BY SPECIALISMPlease indicate your level of proficiency in each of the areas according to the scale ( 1- No experience , 2 – some experience, 3 - competent to perform independently)Cardiovascular SkilsRespiratory SkillNeurological SkillsOrthopaedics SkillsGastrointestinal SkillRenal SkillsEndocrine/Metabolism SkillsGastrointestinal SkillInfection control Skills6. General InformationDo you hold a valid and current British Driver’s Licence? Yes No If Yes, what type? Full Provisional Do you have any endorsements? Yes No Type of endorsement Points Ban 7. Preference regarding workPlease specify which types of work you would prefer. You should tick all appropriate boxes. The service we give depends on accurate, up to date information. Please keep us informed of all developments, in your career and work preferences.PositionsFullPart timeWeekenedType of workNHSPvt hospitalNursing homeIndustryotherShift PatternLive inDaysNightsVisits8. ImmunisationsProof of immunisations with dates must be providedRubella Yes No TB Yes No BCG Yes No Tetanus Yes No Chickenpox Yes No Poliomyelitis Yes No Diphtheria Yes No Hepatitis B Yes No Other Yes No 9. Additional InformationGive details of any additional information which you would like to include in support of your application. Such information, for example, may include skills and/ or achievements which you think maybe of interest, and/or a summary of why you believe that you have the qualities we are looking for. Please provide details of any relatives employed by the Agency and their relationship to you.Add information below10. ReferencesReferences are normally taken up for candidates selected for interview. Give details, names, addresses and email contact information for the most recent employer, must be work-related Referees that must cover the last three years employment. One of the Referees should be your current employer, or if presently unemployed or self- employed, your last employer, or education provider.NameNamePositionPositionCompany and AddressCompany and AddressTelephoneTelephoneEmailEmailRelationship to youRelationship to you 11. Confidentiality DeclarationRegistration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about your clients. On no account must information relating to identifiable client be divulged to anyone other than the manager of the agency. You should not disclose ANY information to your family, friends or neighbours. If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOURMANAGER. Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register. I have read and I understand the above and I agree to abide by the contents thereinConfirm * Yes Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu. Quality Team