nurse application - vision scotland

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nurse application

Employee application

Step 1 of 6

Job role applied for:

Preferred salary/hourly rate:

Name:

First Last

Home address:

Street Address Address Line 2 City ZIP / Postal Code Country

Mobile telephone:

Home telephone:

Email:

D.O.B

Nationality:

Passport no:

Professional details

NMC Pin:

if applicable

PIN expiry:

JOB title:

Qualification:

Date gained:

Next of kin

(please provide contact details of at least one person we can contact in case of emergency)

Name

First Last

Next of kin address:

Street Address Address Line 2 City ZIP / Postal Code Country

Relationship:

Email:

Home telephone:

Mobile telephone:

Employment history

Please supply details of your work history from school to date. Please explain any gaps of 2 weeks or more. CV is acceptable as long as full history with months and years.

Employment details 1

Name & address of employer:

Start date:

End date:

Principal duties:

Band/Grade

Reason for leaving:

Employment details 2

Name & address of employer:

Start date:

End date:

Principal duties:

Band/Grade

Reason for leaving:

Employment details 3

Name & address of employer:

Start date:

End date:

Principal duties:

Band/Grade

Reason for leaving:

Employment details 4

Name & address of employer:

Start date:

End date:

Principal duties:

Band/Grade

Reason for leaving:

Please can you outline any gaps in your employment history:

Reference details

• Please supply the names and work addresses of at least 2 clinical professional referees
• One must be from your present or most recent employer and must be a senior grade to yourself
• The references must cover a period of 3 years in total

Clinical reference 1

Position:

Address

Street Address Address Line 2 City Post code Country

Phone

What was your professional relationship with this person?

From:

To:

Clinical reference 2

Position:

Address

Street Address Address Line 2 City Post code Country

Phone

What was your professional relationship with this person?

From:

To:

Clinical reference 3

Position:

Address

Street Address Address Line 2 City Post code Country

Phone

What was your professional relationship with this person?

From:

To:

Declarations

Compliance(Required)

I understand that I am responsible for ensuring that my personal compliance such as my NMC registration, revalidation, DBS update service and NHS mandatory annual training are kept up to date. If any of these lapse I will be unable to work until I am fully compliant again.

Terms & Conditions(Required)

I confirm that the information given in this application is true.
I am permitted to work in the UK.
I understand that my registration is subject to at least two satisfactory references covering three years and enhanced disclosure from the Disclosure and Baring service.

Working Time Regulations(Required)

For the purpose of the Working Time Regulations 1998 (as amended), I consent to work in excess of an average of 48 hours per week. I understand that I may withdraw this consent by giving Vision Scotland not less than three months’ notice. I understand that my registration with any company within the Vision Scotland can be terminated at any time following unsatisfactory work reports or complaints.

Bank Details(Required)

I confirm that the bank details on this form are complete and correct and that any incorrect or incomplete details can result in a delay of any payments.

Data Protection & Permissions(Required)

I agree that Vision Scotland retains the right to hold this application and any other data required to process it and to pass on to any authorised third party for the purposes of audit and work placements. I agree that Vision Scotland can retain these details for as long as reasonably necessary in accordance with the Data Protection Act.

Disclosure and Barring Update Service Checks(Required)

I agree that Vision Scotland can access the DBS update service portal to check for any changes to my DBS clearances as and when necessary.I agree that Vision Scotland can retain these details for as long as reasonably necessary in accordance with the Data Protection Act.

Handbook Declaration(Required)

I have received (or downloaded) the company handbook and have understood and will comply with it at all times. I am aware that any amendments or new versions will be available on the appropriate company website.

Date signed for all declarations:(Required)

Upload files here:

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 50 MB.

Name

This field is for validation purposes and should be left unchanged.

Proof of Immunity	Please send the following
Varicella	You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity
Tuberculosis	We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)
Rubella, Measles & Mumps	Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and Measles

Proof of Immunity	Please send the following - EPP Candidates Only
Hepatitis B Surface Antigen	Evidence of a negative Surface Antigen Test Report must be an identified validated sample. (IVS)
Hepatitis C	Evidence of a negative antibody test Report must be an identified validated sample. (IVS)
HIV	Evidence of a negative antibody test Report must be an identified validated sample. (IVS)

Employee application

Professional details

Next of kin

Employment history

Employment details 1

Employment details 2

Employment details 3

Employment details 4

Confidential

Medical history

Tuberculosis

EVD (Ebola Virus Disease)

Immunisation History

Declaration

Professional conduct

Rehabilitation of offenders act

Reference details

Clinical reference 1

Clinical reference 2

Clinical reference 3

Declarations