Section One: Personal Details

Title

Fullname

Date of Birth

Address in UK

Permanent address (if non UK resident)

Landline number

Mobile number

Email address

Country of birth

Nationality

Religion

Marital Status
—Please choose an option—SingleMarriedSeparatedDivorcedWidowed

National Insurance Number

Next of kin

Relationship

Address

Contact number

Emergency contact name

Emergency contact number

Do you drive?
YesNo

Vehicle Transmission type
AutomaticManual

Do you own a vehicle in the UK
YesNo

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Section Two: Document Checks

Driving Licence

Type of driving licence held
—Please choose an option—FullProvisionalInternational

Clean licence held (no points)
—Please choose an option—YesNo

Number of years held

Licence number

Expiry date

Origin

Proof of entry into UK for driving licence validation

Passport

Number

Expiry date

Origin

Visa

Number

Expiry date

Origin

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Section Three : Nursing Qualifications

Name of College/Hospital/University

Address

From

To

Qualifications achieved

Name of College/Hospital/University

Address

From

To

Qualifications achieved

Name of College/Hospital/University

Address

From

To

Qualifications achieved

Name of College/Hospital/University

Address

From

To

Qualifications achieved

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Section Four : Full Employment History

Please provide details of your employment history including the reasons for leaving previous positions

Current/Most recent employer

Name

Address

Contact number

Job title

Role/Responsibility

From

Until

Reason for leaving

Previous employer employer

Name

Address

Contact number

Job title

Role/Responsibility

From

Until

Reason for leaving

Previous employer employer

Name

Address

Contact number

Job title

Role/Responsibility

From

Until

Reason for leaving

Additional role information Dates, roles, Employment History (including reasons for gaps) / Reason for Leaving)

Additional Information

Please supply any other additional information to support your application.

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Section Five : References

With your permission references will be taken up immediately before interview. Please provide details of two
professional referees, one must relate to your last period of employment. If this is an agency we will require an
additional referee who can comment on your professional skills and competences. N.B. Referees must be health
professionals who have worked with you previously in a senior clinical capacity.

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Section Six : Health & Welfare Information

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Section Seven : Training

We will need to see original copies of valid certificates

Moving + Manual Handling

Life Support

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Section Eight : Professional Registration & Conduct

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General Data Protection Regulations

Consultus Care & Nursing Limited will need to collect and process personal data about you such as identity
data (your name,
date of birth, marital status, gender etc.), contact data (your address, email address and telephone number)
in order to carry out
our services for you.

We may also need to collect special categories of sensitive personal data (such as information about your
health, genetic data
and biometric data) about you in order to protect your vital interests and safety, and in order to carry out
our services for you.

A full list of the reasons why we need to process your personal data, how we will process your personal data
and what personal
data and sensitive personal data we will collect from you are set out in our Privacy Policy. A copy of this
is available to view on
our website.

You have the right to withdraw your consent at any time where we are relying on your consent in order to
process your data.
This will not affect the lawfulness of any processing carried out before you withdraw your consent. If you
withdraw your consent,
we may not be able to provide our services to you. We will advise you if this is the case at the time you
withdraw your consent.

This information may come from you, your referees, the Disclosure and Barring Service or other persons or
organisations.
We do this in order to:

• Assess your skills, suitability and eligibility to be registered with us as a nurse

• Allow us to meet legislation including the Employment Agency Act 2003 (Conduct of Employment Agencies &
  Employment
  Businesses regulations), which requires an agency to inform a hirer of any information that gives them
  grounds to believe a
  work-seeker is or may be unsuitable

• To assist in finding you employment with appropriate clients if you subsequently become a nurse with
  this agency

I consent to Consultus Care & Nursing Limited processing my personal data and sensitive personal data in
accordance with the Privacy Policy

Rehabilitation of Offenders Act

The nature of the work for which you are applying is considered to be exempt from the provisions of the
Rehabilitation of
Offenders Act 1974 (Exceptions) (Amendment) (England and Wales) Order 2009. Applicants are required to give details
of all
convictions for criminal offences, including those which would otherwise be considered as “spent” by virtue of the
said Act.
Failure to give details of convictions could result in dismissal or disciplinary action by the appropriate
Authority. Information
given will be considered only in relation to this application or applications for other employment carrying this
exemption.

Please give below, or on a separate sheet if preferred, details of all convictions including those which would
otherwise be considered as “spent” and any hearings pending. If you have never been convicted of a criminal
offence please write “no spent or unspent convictions”.

• I declare that the information I have given in this application is to the best of my knowledge true and correct
  and, if selected, I agree to abide by the Consultus Contract for Services

• I declare that to the best of my knowledge there are no medical reasons which would prevent me from
  undertaking the role of a live-in nurse with Consultus

Where did you hear about us?