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

Language

Read

Write

Speak

Decision letter from the NMC? YES NO. Date of Decision letter:

Membership of professional bodies

Name:

Registration/Pin Number

Date of Registration

Expiry Date

IELTS (English Language Testing System) — Exam Score — Academic Level

WORK PERMIT (please tick relevant category)

Not required Required Already granted to previous employer

Other (please explain)

Will you require accommodation in the UK? Yes     No

EMPLOYMENT HISTORY FOR THE LAST 10 YEARS OR BACK TO FULL-TIME EDUCATION ESTABLISHMENT

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:

If you have any further details on employment applicable to this position, please use the "comments" section, or continue on paper and fax or post it to Whitepost.

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 references, 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 refereces prior to the interview? YES NO

I hereby apply to the Whitepost Nursing Agency Ltd for the Adaptation/Supervised Practice coures and understand that any false information stated may result in disqualification of my application, or in dismissal from the course. I agree with the terms and conditions of the Agency governing the Adaptation/Supervised Practice Course.. Signature: _______________________________ Date: _____________ REHABILITATION OF OFFENDERS ACT Because of the nature of the work for which you are applying, this post 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 (Exemption Order) 1975 [9]. Details of any criminal offence in respect of whch you have been cautioned by a constable and which at the time the causion was given, you admitted. 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 (Please note that to withhold relevant information could result in dismissal — with or without notice — should the matter come to light after the appointment).

IF YOU ARE SUCCESSFUL AS AN APPLICANT, AN ENHANCED DISCLOSURE WILL BE CARRIED OUT WITH THE CRIMINAL RECORDS BUREAU. FOR FURTHER INFORMATION ABOUT THE DISCLOSURE SCHEME PLEASE GO TO www.disclosure.gov.uk