Nurse Application Form

QUALIFIED NURSE APPLICATION FORM
Please COMPLETE YOUR ANSWERS IN BLOCK CAPITALS. Answer all the questions in full to the best of your ability - any difficulties should be discussed with a member of the ProCare Management Staff. Your application form may be subject to scrutiny by Local Authority Accreditation Bodies and the Care & Social Services Inspectorate Wales.
SECTION A: PERSONAL DETAILS
Surname*
Mr/Mrs/Miss/Ms*
First Name(s)*
Address & Postcode*
E-Mail Address*
Home Tel. No.
Mobile Tel. No.*
Nat. Ins. No.
Date of Birth*
NMC PIN No*
Renewal Date*
Do you have Indemnity Insurance?*
Policy No.*
Nationality*
Languages Spoken*
If English is not your first language can you provided evidence of competency in English (e.g ILETS Certificate)?*
What is your Marital Status? (Married/Single/Widowed/With Partner)*
Do you have a Full UK Driving Licence?*
Do you own a Car?*
If Yes, Full-Time or Part Time?
Name of Emergency Contact*
Relationship to You*
Contacts Tel. No.*
Alternative No.
Contacts Address & Postcode*
Availability
(Please tick which days, nights and weekends you will be available to work, and write the number of hours per day)
Monday
- Day
Monday
- Night
Max hours per day
Tuesday
- Day
Tuesday
- Night
Max hours per day
Wednesday
- Day
Wednesday
- Night
Max hours per day
Thursday
- Day
Thursday
- Night
Max hours per day
Friday
- Day
Friday
- Night
Max hours per day
Weekend
Saturday
- Day
Saturday
- Night
Max hours per day
Sunday
- Day
Sunday
- Night
Max hours per day

SECTION B: EDUCATION, TRAINING & EMPLOYMENT HISTORY
Please attach an up-to-date C.V. This should contain the following information:
> All Secondary schools, colleges or other training institutions attended
> All qualifications gained (including any obtained through work or other bodies).
> Name and address of ALL employers since leaving full-time education, stating the reason for leaving each position
> Please account for ALL gaps in your employment history, however short.
Upload C.V.
Max. file size: 64 MB.
SECTION C: EMPLOYMENT & CHARACTER REFERENCES
We require a minimum of 2 references. You first reference MUST be from your previous employer (unless there are extenuating reasons why such a reference cannot be obtained). You may not use a relative as a referee.
Referee A
Referee's Name*
Relationship to you (e.g. Manager)*
Address & Postcode*
Telephone No.*
E-Mail Address
Referee B
Referee's Name*
Relationship to you (e.g. Manager)*
Address & Postcode*
Telephone No.*
E-Mail Address
Referee C
Referee's Name
Relationship to you (e.g. Manager)
Address & Postcode
Telephone No.
E-Mail Address
Disclosure
Applications from ex-offenders are welcome and will be considered on their merit. Convictions or cautions that are irrelevant to the job will not be taken into consideration but you are required to disclose ALL convictions or cautions (including 'spent' convictions) by virtue of the Rehabilitation of Offenders Act (Exceptions) Order 1975. Successful applicants will be required to undergo an Enhanced DBS check.
Do you have a Criminal Record? (Includes Cautions, Reprimands & final Warnings*
Are you currently subject to any investigation or disciplinary procedure at work?*
If you have answered 'Yes' to either of these questions please give an outline of the details.
You may offer a fuller explanation at interview.

SECTION E: DECLARATION & SIGNATURE
Applicants Signature
If you are unable to sign-in electronically, please leave blank and fill-in at interview.
Date
On the basis of the information provided above, and at interview, I am satisfied that the Applicant is fit for the purposes of work
Manager's Signature
Date

ProCare Qualified Nurse Application Form 2022

Step 1 of 5

QUALIFIED NURSE APPLICATION FORM

SECTION A: PERSONAL DETAILS

Availability

Weekend

SECTION B: EDUCATION, TRAINING & EMPLOYMENT HISTORY

SECTION C: EMPLOYMENT & CHARACTER REFERENCES

Referee A

Referee B

Referee C

Disclosure

SECTION D: MEDICAL HISTORY

Immunisation or Vaccinations:

Other Information

SECTION E: DECLARATION & SIGNATURE

On the basis of the information provided above, and at interview, I am satisfied that the Applicant is fit for the purposes of work

TRAINING & EXPERIENCES CHECKLIST

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