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Place of Issue:
Visa Expiry Date:
If student, please provide the course details:
REGISTERED GENERAL NURSES ONLY
Current area work:
HEALTH CARE ASSISTANTS
NVQ: Yes/No. Level:
Place of Study:
Name of Employer:
Type of Business:
Please give the names and contact details of two referees. One should be your previous Employer.
EQUAL OPPORTUNITY MONITORING
The information on this form will be used in total confidence and accordance with current data protection legislation. It will help to ensure that the company property monitors and confirms with its policies ralating to equality of opportunity. Information will be used for monitoring only. Our commitment aims to allow our staff to develop their skills and realize their maximum potential as individuals without any wish on the part of the company to limit their opportunity.
PLEASE TICK THE RELEVANT BOX
Please Indicate your age range by ticking one of the boxes below:
Do you consider yourself to have a disability of some kind?
If Yes, give details
PROTECTION OF CHILDREN AND VULNERABLE ADULTS DECLARATION
Has any Social Service Department or Police Service ever conducted an enquiry or investigation into any allegations or that you may pose an actual or potential risk to children or vulnerable adults?
Have you ever been convicted of any offence relating to children or vulnerable adults?
Have you ever been the subject of any discipinary procedure or been asked to leave employment or voluntary activity due to inppropriate behavious towards a child or vulnerable adults?
If yes to any of these question above, please give details.
HEALTH CHECK QUESTIONNAIRE
(Optional/to be filled upon selection)
GP Contact Details:
Have you ever suffered from any of the following:
a)Depression, anxiety state, nervious illness or breakdown
b)Epilepsy or disease of the nervous system
c)Ailment of lungs or chest
d)Spinal problem (backache)
e)Arthritis, Rheumatism or Gout etc
f)Any heart or circulatory, including blood problems
g)Illness of the kidneys, bladder, liveror glands
Are you presently taking medication or undergoing treatment. If so give details:
How many working days have you been absent from working during the last 12 months (apart from holidays):
Are you pregnant?
Additional details (if necessary):
Please provide your bank details where you would like your payment to be sent.
Name in Account:
Type of Account:
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