Application Form - Connect Nursing Ltd

Title*
First Name*
Last Name*
Full Address*
Postcode*
Home Telephone*
Mobile Number*
Email
NI Number
Date
Date Format: MM slash DD slash YYYY
Passport Number*
Visa Status (If applicable)*
Nationality*
Next of Kin
Name*
Address*
Postcode*
Telephone*

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University / College Name*
From*
Date Format: MM slash DD slash YYYY

Dates Attended
To*
Date Format: MM slash DD slash YYYY

Dates Attended
Qualification Achieved*
NVQ Level*

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Name*
Registration Number*
Registration Since*
Expires*
Date Format: MM slash DD slash YYYY

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From*
Date Format: MM slash DD slash YYYY

Dates Attended
To*
Date Format: MM slash DD slash YYYY

Dates Attended
Name of Employer*
Employer Address*
Postcode*
Duties*
Reason For Leaving*

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Referee 1
Name*
Position*
Company Name*
Company Address*
Postcode*
Telephone*
Email*
Enter Email Confirm Email
Referee 2
Name*
Position*
Company Name*
Company Address*
Postcode*
Telephone*
Email*
Enter Email Confirm Email

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This position is considered exempt from provisions of the Rehabilitation of offenders Act 1974, as contained in the Exemptions Amendment 1986. You are required to disclose information concerning all convictions including those, which for other purposes would be regarded as spent under the Act. All information will be treated as confidential and taken into account where the offence is relevant.
Convictions. Past, current and pending.
Please list below all convictions, past, current and pending.
Full Name*
Date
Date Format: MM slash DD slash YYYY

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This position is considered exempt from provisions of the Rehabilitation of offenders Act 1974, as contained in the Exemptions Amendment 1986. You are required to disclose information concerning all convictions including those, which for other purposes would be regarded as spent under the Act. All information will be treated as confidential and taken into account where the offence is relevant.

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Mandatory training certificate
Date attended*
Date Format: MM slash DD slash YYYY
Expiry Date*
Date Format: MM slash DD slash YYYY
Medication Administration
Date attended*
Date Format: MM slash DD slash YYYY
Expiry Date*
Date Format: MM slash DD slash YYYY
Additional specialist or complex training:
Course name
Date attended*
Date Format: MM slash DD slash YYYY
Expiry Date*
Date Format: MM slash DD slash YYYY
EQUAL OPPORTUNITIES MONITORING
Connect Nursing aims to be an equal opportunities employer and we select solely on merit irrespective of disability, race, creed, colour, nationality, ethnic origin, sex, marital status or sexual orientation when selecting, recruiting, training and or promoting staff. In order to monitor the effectiveness of our equal opportunities policy, we request all applicants to provide the information indicated. Please note: Ethnic minority questions are not about nationality, place of birth or citizenship. They are about colour and broad ethnic groups- UK citizens can belong in any group. In promoting its Equal Opportunities Policy, the Agency will try to meet in full the legal requirements placed on it by the Race Relations Act 1976, the Sex Discrimination Act 1975, the measures relating to the employment of disabled people and codes of practice now in force. This information is for monitoring purposes only and will be treated in the strictest confidence.
Sex*
Ethnicity*
Age Group*
Disabilities*
Working Time Regulations
I agree with Connect Nursing Limited that the limit stated on Regulation 4(1) of the Working Time Regulations 1998, of 48 hours maximum shall not apply to me. I understand that my hours of work may now exceed those stated in the Working Times Regulations. This agreement shall apply from the date of signing below. I understand that I can terminate this agreement at any time with 4 weeks’ written notice. I agree to comply with the policies and procedures of Connect Nursing Limited.
I accept*
- By clicking "I accept" I agree to comply with the policies and procedures of Connect Nursing Limited.

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I can confirm that I am not under investigation by any professional body such as the NMC etc. Nor am I being investigated by my employer previous or current. I agree to disclose any future investigations to Connect Nursing Limited as soon as possible. I also agree to inform Connect Nursing of any criminal Investigations against me.
*
- I accept the above statement is true
I can confirm that I am not under investigation by any professional body such as the NMC etc. Nor am I being investigated by my employer previous or current. I agree to disclose any future investigations to Connect Nursing Limited as soon as possible. I also agree to inform Connect Nursing of any criminal Investigations against me.
*
- I accept the above statement is true
I have read and understood Connect Nursing’s privacy policy
*
- I accept I have read and understood the policy
Bank Details
Bank name*
Bank address*
Account holder name*
Sort code*
Account number*
Is this account in your name?*
- Yes
- No
If not, what is your relationship with the named person?
National Insurance Number*
Your current address*
Postcode*
How did you hear about Connect Nursing?*
Referred By

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Step 1 of 11 - Personal Details

Next of Kin

Referee 1

Referee 2

Have you ever had in your life any of the following?

Immunisation Records

Doctors Information

Mandatory training certificate

Medication Administration

Additional specialist or complex training:

EQUAL OPPORTUNITIES MONITORING

Working Time Regulations

Bank Details

Guide: