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NURSE APPLICATION FORM


Please complete this form in black ink and complete all sections





Position Applied for





Your Surname and Initials


Data Protection Statement
The personal information (data) collected on this form, and on the attachments, (which includes the collection of sensitive personal data) are collected for the purposes of recruitment, personnel administration (for new employees) and monitoring. Unless you direct otherwise (for example in a situation where you would like this Application kept on file for future vacancies) the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6 months. It is the policy of the Agency to protect, and keep secure, all personal data collected. All personal data is processed for the purposes of recruitment, and, in the case of successful Applicants, for the satisfactory administration of their employment, and for no other purpose.


Equality of Opportunity Statement



The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.

Which of the following applies to you?

Qualified Nurse Student Nurse Qualified Nurse abroad(not registered in the UK) Please as appropriate

NMC pin number

(please enclose copy of statement of entry and pin card)


Expiry Date



1.Personal Details



Title






Surname





Maiden Name




Previous surnames (if any)





Forenames (in full)





Address






Post Code


Telephone

Home

Work

Mobile











Email address



Nationality




May we contact you at work?

Yes No Please as appropriate

Date of Birth




National Insurance Number




Next of Kin to be notified in case of emergency: Name




Address






Post Code


Telephone

Home

Work

Mobile











Relationship to you



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