Application Form

Have you ever been dismissed from a professional or nursing post? Yes No If 'yes' please give details below: Date of Conviction: Nature of Conviction: 12. Details of any convictions... continued. Are you currently suspended, on notice of dismissal from your employment or under investigation from any employer? Yes No If ...
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Application Form A-Best Nursing & Care 65 Wellington Rd South,

Please complete all sections of the application form and return to the address below. Please continue on separate sheets of paper, if necessary. The information provided on this form will be used as part of the selection process.

Stockport SK1 3RU Tel: 0161 222 9445 Email: [email protected] www.abestcare.co.uk

Please affix a standard Passport sized photo’s below

1. Personal Details Please complete this section using your full NMC registered name. Title: Mr

Mrs

Ms

Miss

First Name: Surname: Sex: Male

Female

Other

Date of Birth: Marital Status: Other Names: NMC Pin No:

2. Contact Details

3. Next of Kin Contact Details

Current Address:

Contact Name: Relationship: Address:

Postcode: Work Telephone: Home Telephone: Mobile:

Postcode:

Email Address

1st Contact No: 2nd Contact No: Email Address:

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4 a). Education

istory

ease i e detai s o your education history. continue on a se arate iece o

Name of School / College / University

ualification / Course

Date From:

Date To:

a er i necessary)

Additional Details:

Name of School / College / University

ualification / Course

Date From:

Date To:

Additional Details:

Name of School / College / University

ualification / Course

Date From:

Date To:

Additional Details:

Name of School / College / University

ualification / Course

Date From:

Date To:

Additional Details:

A-Best Nursing & Care

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4 b). mployement History ease i e detai o your e oye ent o er the ast years. a s o er onths ust e accounted or. nc ude the onth and the year startin ith your current or ast o continue on a se arate iece o a er i necessary).

o

.

ob Title:

mployer s Name: Date To:

Date From: Reason for Leaving:

. ob Title:

mployer s Name: Date To:

Date From: Reason for Leaving:

. mployer s Name:

ob Title:

Date To:

Date From: Reason for Leaving:

4.

mployer s Name:

ob Title:

Date To:

Date From: Reason for Leaving:

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5. Immigration Status British/EC Nation: Yes

9. Bank Details... Continued

No

Marital Status:

Passport No:

Other Names:

Expiry Date:

IBAN:

Issued at:

Swift/BIC:

Type of visa held (if any):

Branch Address:

Expiry Date:

6. Professional Society / Union

Postcode:

Name of Society/Union:

10. References (please provide two

Type of Membership:

references)

Renewal Date: Reference 1:

Membership PIN No: Are you currently under investigation by the NMC or any other organisation? Yes

No

Name: NMC Pin (if applicable): Address:

7. Tax Status 1. PAYE:

Yes

No

Postcode:

P45 enclosed:

Yes

No

Mobile:

P46 enclosed:

Yes

No

Fax:

2. LTD company: Yes

No

Email:

VAT Registered : Yes

No Reference 2:

Please provide certificate of incorporatio