Application for Employment for Agency Work or Permanent Position:

Date:

Your specialty(s)

Surname:	Forenames:
Previous name (if applicable):	National insurance number:
Permanent Address: Email address: Telephone no. (business) Telephone no. (private)	Next of Kin to be contacted in case of emergency: Name Address Relationship Daytime telephone no.

Age:

Date of Birth:

Country of Birth:

Nationality:

Marital Status:

Number and age of dependents

KNOWLEDGE OF FOREIGN LANGUAGES (Grade Good, Fair or Slight)

Language

Read

Write

Speak

REGISTRATION WITH THE U.K.C.C. YES NO

Membership of professional bodies

Registration No.

Date of Registration

Expiry Date

Investigations Pending

WORK PERMIT (please tick relevant category)

Not required Required Already granted to previous employer

Other (please explain)

Please indicate the length of time you would like to work in the UK.

3 month contract Permanent position

6 month contract Casual work

12 month contract

Which clinical area/s do you prefer to work in: Which cities or geographical areas would you like to work in or close to, within the U.K.? When will you be able to start work? Will you require accommodation in the UK? Yes     No

EMPLOYMENT HISTORY - OVER MINIMUM OF LAST 5 YEARS

Employment	Job title and Principal Duties	Reason for Leaving/Wishing to Leave
1. Name and Address: Dates from -- to: Wages or Salary: Start -- last: Benefits:
2. Name and Address: Dates from -- to: Wages or Salary: Start -- last: Benefits:
3. Name and Address: Dates from -- to: Wages or Salary: Start -- last: Benefits:

Please indicate in the comments section if you have more employer reports.
Use a separate sheet and mail or fax this information to Whitepost. Thank you.

EDUCATION:

Name of schools attended after the age of eleven (include dates mo/yr, and examinations passed Further education: Title of courses - address - dates of course Details of courses Training -- addresses -- dates

LEISURE INTERESTS:

What are your main interests and hobbies

ADDITIONAL INFORMATION:

Any other information you may feel is relevant to your application, including your past experience and achievements and how you consider they relate to the requirements of this post.

REFERENCES:

Give the names and addresses of two referees, not relatives, one of whom should be from your present, or last employment

References will not be contacted without your permission.
May we approach the above referees prior to the interview? YES NO

I hereby apply for employment with the Whitepost Nursing Agency, and understand that any false information stated herein may result in disqualification of my application, or in dismissal if I am employed by the Agency.

Signature: _______________________________ Date: _____________

REHABILITATION OF OFFENDERS ACT
Because of the nature of the work for which you are applying, this post is except from the provisions of Section 4(2) of the Rehabilitation of Offenders Act, 1974 by virtue of the Rehabilitation of Offenders Act, 1974 (Exemption) Order 1875.
Applicants are therefore not entitled to withhold information about convictions which for other purposes are "spent" under the provisions of the Act.

In this respect, is there anything you wish to bring to the attention of the prospective employer? YES NO

I understand that the Agency may use its discretion to inform my Registration and Professional bodies as well as my employers about falsification of information.

(Please not that to withhold relevant information could result in dismissal -- with or without notice -- should the matter come to light after the appointment).