Application Form - Please complete complete all sections

1. Personal Details

House #, Street Name  *
City, Town, County,  *
Country  *
Post Code
House #, Street Name
City, Town, County,
Post Code

2. Educational Qualifications

3. Employment History

Start with the most recent an cover at least 10years

4. Training

e.g. Manual handling, CPR, infection control, first aid etc., (please provide certificates)

5. Professional Details

The 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 etc
Please 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)

6. General Information

7. Preference regarding work

Please 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.

8. Immunisations

Proof of immunisations with dates must be provided

9. Additional Information

Give 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.

10. References

References 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.

11. Confidentiality Declaration

Registration 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 therein
Quality Team