Nurse Application Form

Restriction To Practice

Have you ever been the subject of any professional conduct complaints with any Trust/Organisation?

Yes
No

If yes please specify

Are you aware of any professional conduct complaints being considered against you?

Yes
No

If yes, please specify

Availability And Work Preference

What Type of Work are you looking for?

Full Time Work
Ad-hoc Shifts

What days do you prefer?

Weekdays
Weekend/Bank Holidays

What is your preferred shift type(s)

Long Day
Early
Late
Night

How far are you willing to travel

Are there any site you would not want to work at(please specify reason)

Employment History

Please give FULL details of all previous employment (including agency work) to cover the last 10 years

Employer's name and address

Position Held

Date of employment

Reason for leaving

Employer's name and address 2

Date of employment 2

Position Held 2

Reason for leaving 2

Employer's name and address 3

Date of employment 3

Position Held 3

Reason for leaving 3

Gap in employment

Date from

Date to

Reason

Date from 2

Date to 2

Reason 2

Date from 3

Date to 3

Reason 3

Dismissal and Disciplinary

Have you ever been dismissed or faced disciplinary action by any of your previous employers

Yes
No

If yes, please specify reason

Referee1

Position

Relationship

Organisation

Address of 1st Referee

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Referee1 *

Email Referee1 *

Referee2

Position2

Relationship 2

Organisation 2

Address of 2nd Referee

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Organisation 3

Phone Referee2 *

Email Referee 2 *

Referee3

Position3

Relationship 3

Organisation 3

Address of 3rd Referee

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Referee 3 *

Email Referee 3 *

Working Time Regulations 1998 -Opt Out Declaration

The working time regulations act 1998(“the regulations”) requires to limit your average weekly working time to 48 hours unless you agree with the limit shall not apply to you. To have an agreement with you. It proposes an agreement (which shall apply until terminated by notice) on basis that:

a) The 48-hour limit on average weekly time will not apply to you;

b) You may terminate the agreement (so that the 48-hour time limit would apply to you) by giving written notice (3 months) in writing to the consultant to whom you usually report to.

Yes, I agree to opt out; please do not limit the hours I work via Divine Consultant

Under the regulations, Divine Consultant must keep records relating to your working time. This is the case whether or not you reach an agreement with the company about waiving working limits. If you accept the company’s proposal, please accept the agreement below, this will be accepted as your signature.

Yes, I agree to opt out; please do not limit the hours I work via Divine Consultant
No, I do not agree to opt out; please limit the hours I work via Divine Consultant

Date opted in or out of Time Regulations 1998 *

Personal Details

Right To Work

Next of Kin/Emergency Contact Details

Professional Registration

Professional Membership

Appraisal

Restriction To Practice

Availability And Work Preference

Employment History

Please give FULL details of all previous employment (including agency work) to cover the last 10 years

Gap in employment

Dismissal and Disciplinary

Referee1

Referee2

Referee3

Working Time Regulations 1998 -Opt Out Declaration