Position Applying For

Last Name

First Name

Address

Telephone Number

Do you have any physical disabilities or health conditions that could affect this application, if so please give details?

Have you received compensation for injuries, if so please give details?

Have you ever been convicted of a criminal offence? If so, please give details

How many days have you taken off sick in the last 12 months?

How many days have you been absent from work for reasons other than sickness in the last 12 months?

Current Annual or Hourly Wage

Expected Annual or Hourly Wage

Are you prepared to work full time or part time?

If part Time, please give details of hours.

Have you previously been employed by a Trustworth Group Nursing Home?

If yes, please give details.

Do you have any relatives working for us, if so please give their names and details of the relationship.

When are you available to start work?

List any specific skills, experience or qualifications you have relevant to the post.

Will this be your main job or your second job?

If you have ever been employed in a role where you were caring for vunerable adults or care of the elderly, please state your reasons for leaving.

Have you ever been subjected to disciplinary action? If so, please give details.

Please specify any previous employers who you would prefer us not to contact.

If offered this position, would you continue to work in any other capacity?

Please give details of schools, colleges, university or other institutions attended, with dates and qualifications achieved including professional membership.

Do you have any of these qualifications? RMN or RGN.

If so, please give NMC no.

Expiry date:

Please give details of two referees. One must be your most recent employer. If you have previously worked in care of the elderly, one referee must be from an employer in this field. Please include their name, occupation, name and address of company and a telephone number/e-mail address.

Please answer YES or NO to the following - if answer is yes - please give details:

Have you ever had an operation?

Have you ever been seriously injured?

Have you received in-patient treatment for a physical or mental condition?

Have you been refused or dismissed from employent for health reasons?

Have you received a disability pension?

Have you been registered disabled?

Have you been made ill by your work?

Have you been refused a drivers license because of ill health?

Have you received any of the following or any other vaccinations - Diphtheria, Tetanus, Polio, MMR, Meningitis C, Hepatitis B, Influenza (flu). Please provide dates if possible.

Have you suffered from or ever had heart trouble

Have you suffered from or ever had skin disease?

Have you suffered from or ever had eye trouble?

Have you suffered from or ever had back problems?

Have you suffered from or ever had lung trouble?

Have you suffered from or ever had stomach trouble?

Have you suffered from or ever had ear trouble?

Do you take medicine regularly?

Do you suffer from any other ailments?

Do you need glasses to read?

If yes to any of the above - please give details.

I am prepared to undergo a medical examination if required and confirm that to the best of my knowledge there are no medical reasons that would prevent me from undertaking the duties of the post. I have disclosed all information relevant to this application that may affect my suitability for the post. I confirm that the above statements and those in my interview are true and accurate and that any misrepresentation will invalidate my application and if employed could result in my immediate dismissal.