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To apply please complete the full application form.

Application Form

1 Personal Details

• Name (Required)
  • Dr/Miss/Mr/Mrs/Ms/Prof./Rev. Title First Last
• Maiden Name (if applicable)
• Home Phone Number
• Mobile Number (Required)
• Email (Required)
• Address (Required)
  • Street Address
  • Address Line 2
  • City/Town
  • County
  • Postcode
• Right to Work (Required)
  • I confirm that I have a right to work in the UK.

2 Additional Details

• Your National Insurance Number: (Required)
• Are you registered with NMC or NISCC? (Required)
  • Yes
  • No
• What is your NMC/NISCC number? (Required)
• What is your NMC/NISCC certificate expiry date? (Required)
• Do you have your own form of transport? (Required)
  • Yes
  • No
• Driving Licence No.
• Have you worked for an agency within the last 3 months? (Required)
  • Yes
  • No
• Which agency or agencies did you work for? (Required)

3 Next of Kin

• Name (Required)
• Maiden Name (if applicable)
• Address (Required)
• Contact No. (Required)
• Relationship to you: (Required)
• Consent (Required)
  • Please tick to confirm that the person named has given their consent to be contacted as your next of kin.

4 Convictions/Investigations

INVESTIGATIONS/REPORTS

• Have you ever been the subject of an Adult or Child Abuse investigation or been previously referred to the Independent Safeguarding Authority/DBS as a result of misconduct involving a child or a vulnerable adult? (Required)
  • Yes
  • No
• If yes, provide full details below: (Required)
• Have you ever been reported to NMC/NISCC? (Required)
  • Yes
  • No
• If yes, provide full details below: (Required)

CONVICTIONS/OFFENCES

• Due to the services provided the majority of posts within the Company are governed by the Protection of Children & Vulnerable Adults (NI) Order 2003 and the Rehabilitation of Offenders (Exceptions) Order NI 1979. Disclosure of offences will not automatically debar you from applying for the post.
• Do you have any convictions that are not “protected” as defined by the Rehabilitation of Offenders (Northern Ireland) Order 1978, as amended in 2014? (Required)
  • Yes
  • No
• If yes, provide full details below: (Required)
• All disclosures will be reviewed for compatibility with the post.

5 Employment

• Current/Most Recent Employer
  • Job Title
  • Employer (name & address)
  • Start Date (dd/mm/yy)
  • End Date (dd/mm/yy)
  • Hourly Rate/Salary
  • Reason for leaving
• Previous Employers (please list all since leaving school starting with most recent)
  • Job Title
  • Employer (name & address)
  • Start Date (dd/mm/yy)
  • End Date (dd/mm/yy)
  • Hourly Rate/Salary
  • Reason for leaving
• Please click on the + button to add more employers.
• Do you need to add anymore employers to your employment history? (Required)
  • Yes
  • No
• Please complete a paper application form with your remaining previous employers.

Break in Employment

• Do you need to provide details of any periods you were not working since leaving school? (Required)
  • Yes
  • No
• Date from (Required)
• Date to (Required)
• Please provide details for this break in employment: (Required)
• Do you need to provide any further details of period you were not working? (Required)
  • Yes
  • No
• Please provide further details of dates and reasons for further periods of not working: (Required)

6 Criteria

• Please provide any other information which may be relevant to this application, detailing how you meet each of the criteria: (Required)

7 References

• Please complete the details of two reference which must include your present/most recent employer.

Relatives cannot be named as referees. Character references can be sought from a GP, religious official or friend who is not a relative.

We will only seek references after an offer of employment is accepted. We may seek references from your previous employers if one from your current/most recent employer is unobtainable. Please note we are required to obtain a reference from all previous employments within Health & Social Care. Please complete reference details in full.

Reference 1 (Most Recent Employer)

• Name of Reference 1 (Most Recent Employer) (Required)
• Company Name
• Address (inc. postcode) (Required)
• Telephone Number (Required)
• Email address (Required)
• Capacity Known (Required)
• How does this person know you?
• Employed From
• Employed To

Reference 2 (Character/Employer)

• Is this a character or employer reference? (Required)
  • Character
  • Employer
• Name of Reference 2 (Employer/Character) (Required)
• Company Name
• Address (inc. postcode) (Required)
• Telephone Number (Required)
• Email address (Required)
• Capacity Known (Required)
• How does this person know you?
• Employed From
• Employed To

Consent

• Please tick the box to allow us to complete and receive references for yourself.

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