Print, Complete and Post so Select FILE then PRINT from the drop down menus above
To get back to the MAIN WEB SITE - Select FILE and CLOSE
(If there is insufficient room in any section, please continue on a separate sheet of paper)

NEW CONCEPT CARE & NURSING
Application for Nurse Agency Membership

Personal Details
Name Date of Birth
Previous Names Country of Birth
Nationality. National Insurance No
Telephone No Do you have transport?

Address:

 

 

 How far are you prepared to travel from home?
Size of Uniform Required: Do you hold a Current and Full Driving Licence?
UKCC PIN No.

Renewal Date

Professional Qualifications:
Qualification Level/Part Year Obtained

 

 

 

 

 

    

Areas of Specialism:
Area/Topic Length of time worked in area

 

 

 

 

  

 


Training undertaken (course details, venue etc.) in the last 5 years:

Course details and venues Dates

 

 

 

 

 

 

  

Preferences for type of work:

 

 

 

 


When would you be available to work?
Which days of the week? During which time(s) of the day?

 

 

 

 

 

  


Current or most recent employer:

Name and Address Post Held From To

 

 

 

      

 

References:
Please provide the details of 2 people who have consented to give a reference on your behalf, and can give a reasonable assessment of your capabilities to fulfil the demands of this post. Both should hold either medical or Nursing qualifications, or hold positions within a field of care. One MUST be your current or most recent employer.

 
referee 1
referee 2
Name

    

Address

 

 

    
Position/Role of referee    
Tel:    

May we contact them
before interview?

    


Emergency Contact Details: Please provide details of your next-of-kin or another person that we should contact in the event of an emergency.

Name: Telephone No

Address:

 

 Relationship to you:

General Education : (to include GSCE's, O-Levels, Degrees, Diplomas etc.
Subject
Level
Grade
Year Obtained

 

 

 

 

 

 

 

      

 


Employment History (beginning with your current or most recent employer)

Name and Address of Employer
Post Held
From
To
Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

        

 

Immigration Regulations :

In order to comply with current immigration regulations will you require a work permit before you take up work with New Concept Care & Nursing.

Rehabilitation of Offenders Act 1974 :

Because of the nature of the work for which you are applying, this is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitation of Offenders Act 1974 (exceptions)Order 1975. Therefore you are required to disclose all informations about convictions which for other purposes are 'spent' under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation to this application.

Do you have any criminal convictions? Delete as appropriate:- YES/NO

(If YES, please provide details on a separate sheet of paper) - an Enhanced CRB check will be completed prior to employment



Declaration by Applicant

I confirm that the information contained in this application is correct, and that all the relevant details have been given. I understand that, if accepted as a Nurse Agency Member, any offer of work is subject to the information contained herein. I understand that any false statement may disqualify me from Agency Membership.

I understand that New Concept Care & Nursing will confirm my registration status with the NMC

I have read and understood the above statement regarding the Rehabilitation of Offenders Act.


Signature……………………………………….Date………………………….


ON A SEPARATE SHEET OF PAPER, PLEASE PROVIDE DETAILS OF THE SKILLS AND QUALITIES YOU HAVE,
WHICH WOULD MAKE YOU A SUITABLE NURSE AGENCY MEMBER. ALSO, PLEASE TELL US WHY YOU ARE INTERESTED IN WORKING FOR A NURSING AGENCY.
THANKYOU.


. :