Application Form

Personal Details

Position

Title

Your Qualifications

	ANP
	RNLD
	RHV
	EN
	RSCN

	RM
	RGN
	RMN
	RH
	ENM

	ENG
	ENMH
	RNMH
	HCA
	SW

NMC Pin Number

National Insurance No:

NMC Pin Number Expiry:

Please specify what you are looking for:

Permanent

Temporary/Contract

Both

First Name:

Surname:

Address:

Postcode:

Telephone Home:

Telephone Work:

Mobile:

Email:

Marital Status:

Maiden Name:

Date of Birth:

Place of Birth:

Nationality:

Religion:

Full Driving Licence:

Yes:

No:

Car Owner:

Yes:

No:

Work Permit?

Yes:

No:

if yes, give details:

Do you belong to a Union?

Yes:

No:

if yes, give details:

How far are you prepared to travel to work?

Bank/Building Society Details

Building Society Roll No:		Bank Name:
Account Holders Name:
Sort Code:		Account Number:

I authorise Divine Blessing International Ltd to pay my weekly earnings directly into my bank or building society whose details I have given above. I confirm that I will notify Divine Blessing International in writing of any changes to these details.

If you understand and agree with the above, please tick the box:

If you require to be paid through a UK Limited or Composite company, then the following details are required. N.B. Certificates of registration will be required:

Company Name:		Company Reg No:
Company VAT No (if VAT payments req):

Working Time Directive

Regulation 4 of the Working Time Directive requires that a worker’s average time must not exceed 48 hours within one week unless the worker agrees in writing to exceed this limit. If a temporary employee is to lawfully work more than 48 hours in that period, they must sign an opt-out agreement to stipulate this.

If you are prepared to work more than 48 hours per week, please sign the declaration below in that that we may employ you legally should you exceed this amount. You may withdraw from this agreement at any time providing you give us one weeks notice.

If you understand and agree with the above, please tick the box:

NMC Code of Conduct - Nurses only

The NMC Booklet for guidelines for the administration of medicines clearly states;

“The administration of medicines is an important aspect of the professional practice of persons whose names are on the Council’s register. It is not solely a mechanistic task to be performed in strict compliance with the written prescription of a medical practitioner. It requires thought and judgement”.

As a registered nurse, midwife or specialist community public health nurse, you are accountable for your actions and omissions. In administering any medication, you must exercise your professional judgement and apply your knowledge and skill in the given situation.

In exercising your professional accountability in the best interests of your patients, you must;

Know the normal dosage, side effects, precautions and contra-indications
Be certain of the identity of the patient
Be aware of the patients’ care plan
Check that the prescription, or the label on the medicine is clearly written
Consider the method of administration, route and timing of the administration
Check the expiry date
Check that the patient isn’t allergic
Make a clear, accurate and immediate record of all medicine administered

If you make an error, you must report it immediately to the line manager or your employer.
You are jeopardising your NMC Pin Number if you are not complying by the Code of Conduct.

If you understand and agree with the above, please tick the box:

Certification

Moving & Handling:

Yes:

No:

CPR/First Aid:

Yes:

No:

Expiry:

COSHH:

Yes:

No:

RIDDOR:

Yes:

No:

Expiry:

Health & Safety:

Yes:

No:

Fire Safety:

Yes:

No:

Expiry:

Rehabilitation of Offenders Act

the Rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are therefore, not entitled to withhold information about convictions which for other purposes are spent under the provisions of the Act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an application for positions in which the Order applies and should be entered at the end of any particulars you give in support of your application. A COPY OF OUR WRITTEN POLICIES IS AVAILABLE ON REQUEST. A CRIMINAL RECORD WILL NOT NECESSARILY BE A BAR TO OBTAINING A POSITION.

Have you ever been convicted of a criminal Offence?

Yes:

No:

Do you have any spent or unspent criminal conviction?
Any conviction will require a written statement of each event and how it doesn’t affect your application

Yes:

No:

Have you ever been involved in court proceedings?

Yes:

No:

PLEASE SUPPLY ANY ADDITIONAL INFORMATION WHICH YOU THINK MAY BE RELEVANT IN SUPPORT OF YOUR APPLICATION.

I confirm that the information that I have provided in support of this application is complete and true and understand that knowingly to make a false statement is a criminal offence.

Health Declaration

All members are required to complete this Health Declaration. Any feedback will not effect your application
General Practitioner/Occupational Health Dept:
Address:
Telephone:		Postcode:

Please give us your NEXT OF KIN details in case of an emergency:
Name:		Relationship:
Address:
Telephone:		Postcode:

Health Assessment

General Health Questions

n/a

Details (if Y, you must include details).

Do you have any impairment which may affect your ability to work safely?

Do you have any eyesight problems not corrected with glasses?

Do you have any hearing problems not corrected with a hearing aid?

Do you have any difficulty in standing, bending, lifting or other movements?

Have you seen a doctor in the last year for any kind of health problem?

Are you having any treatment or investigations of any kind at the moment?

Do you smoke?

Have you ever had any kind of skin problem?

Have you ever had any kind of back problem?

Have you ever had any kind of problem with your joints, including pain, swelling or stiffness?

Have you ever had any mental illness or psychological problems?

Have you ever had a drug or alcohol problem?

Have you ever had fits, blackouts or epilepsy?

Do you have any allergies?

Have you ever had asthma, bronchitis or chest problems?

Have you ever had treatment for Tuberculosis (TB)?

Have you ever had Chickenpox

Have you ever had hepatitis or jaundice?

Have you ever had diabetes, thyroid or gland problems?

Have you ever had measles/German measles?

Have you ever been exposed to any high-risk infections?

Pregnancy (i.e. report to Service Manager)

What is your height?

What is your weight?

Please use this space to highlight any details of the above. Please include: What type of treatment did you receive? Were you admitted to Hospital, unable to work or restricted in doing your normal activities etc. Does the condition continue to affect you?

Have you ever been vaccinated or tested for/against the following?

n/a

Dates/Test Results:

Rubella (German Measles)

Mumps

Heaf, Mantoux or Tine

BCG (TV Vaccination)

Hep A -

Injection 1:

Injection 2:

Injection 3:

Blood Test:

Booster Date:

Hepatitis B

Hepatitis C

Copy of immunity status: immune>100 iu/ml not immune non responder

Exposure Prone Procedures inc. HIV.

Client has my permission to contact my General Practitioner to verify any of this declaration. If I have willingly withheld any other relevant medical details I realise I may be subject to disciplinary action. I consider myself fit for employment. I give my consent to The Nationwide Accreditation Bureau (NAB) on behalf of Client to conduct this review.

If you understand and agree with the above, please tick the box:

Keywording for Nurses only

Please tick the areas that describe your work experience. Remember that you are held professionally accountable.

Specialism	< 6 months	> 6 months	1 – 2 years	2 + years
A & E
Anaesthetic Trained
Ante Natal
Cardiac
Cardiothoratic
Care of the Elderly
Chemotherapy
Community Nursing
Cosmetic Surgery
CSSD
Day Care Centre
Day Surgery
Dental
District Nursing
Family Planning
GU Med
Gynaecology
Haematology
Health Visitors
High Dep Unit (HDU)
Home Care
Hospices
Hospitals
In Charge Duties
Intensive Care Unit
ITU Psychiatric
Learning Disability
Medical
MAU/PAU
Mental Health
Midwifery
Neonatal
Neurology
Nursing Homes
Occupational Health
DDP/ODA
Oncology
Ophthalmology
Orthopaedics
Out Patients
Paediatric
PICU
Practice Nurse
Prisons
Radiology
Recovery
Renal
Residential Homes
SCBU
School Nurse
Scrub
Stoma Care
Surgical
Termination Clinic
Theatre
Urology

Keywording for Carers only

Please tick the areas that describe your work experience. Remember that you are held professionally accountable

Specialism	< 6 months	> 6 months	1 – 2 years	2 + years
Nursing Homes
Residential Homes
Private Homes
Hospitals
Schools
Learning Disability
Mental Health
Home Care

Equal Opportunities

The company views itself as an equal opportunity employer; however we are continuously adapting and improving our procedures and practices. It is in this capacity that the company pledges it’s continued commitment to developing positive policies to promote equal opportunities in the work place and prohibiting unlawful or unfair discrimination on the grounds of a members age, sex, marital status, race colour, disability, nationality, or ethic origin. We also firmly believe that discrimination on the grounds of sexual orientation, religion, age or other reasons shall not be allowed.

In order to ensure that these policies are being carried out and working effectively and for no other purpose, all members are asked to provide this information and therefore the information remains confidential and for analysis purposes only. Your local office manager will be able to help you if you have any queries.

Gender:

Male:

Female:

Ethnic Origin:

	White
	Black Caribbean
	Asian
	Pakistani
	Chinese

	Irish
	Bangladeshi
	Black African
	Other
	Please specify:

I confirm that this information is true and correct:

Professional References

We require references from last or most recent employer. Must be an employer and not a colleague.
Name:		Name:
Position Held:		Position Held:
Name of Organisation:		Name of Organisation:
Department:		Department:
Address:		Address:
Telephone:		Telephone:
Fax/Email:		Fax/Email:

Employment History

Give details of employment history during past ten years, most recent first:
From:	To:	Employer Name:
Work Title:		Grade:
Full time	Part time	Salary:
Main Responsibilities:
Dept/Ward:		Reason for leaving:
Give details of employment history during past ten years, most recent first:
From:	To:	Employer Name:
Work Title:		Grade:
Full time	Part time	Salary:
Main Responsibilities:
Dept/Ward:		Reason for leaving:
Have you been dismissed from any employment?
When would you be available from interview?
What is your employment notice?
Do you have any holiday commitments in next 12mths?
Do you know anyone in Divine Blessing International Ltd?

Declaration

I declare that the information given in this application form is true and complete to the best of my knowledge and belief. I have read and understood the Terms of Engagement booklet given to me. I agree to comply with the current Health & Safety at Work Act. I understand that my appointment is subject to the receipt of a minimum of two satisfactory references and is subject to Disclosure. I authorise Divine Blessing International Ltd to make any other enquiries they may deem necessary to support my application. I agree to respect the confidentiality of patients and clients and any other information I may have access at all times. I understand that I can access the policies and procedures and staff handbook via request from Divine Blessing International Ltd.

If you understand and agree with the above, please tick the box:

Tel: +44(0)5603 448 791

QUALIFICATIONS

We have a wide range of vacancies from some of the most prestigious names in healthcare. We are currently looking for:

Qualification

Specialities

Auxiliary	ITU
NVQ	NICU
NNEB	CCU
RM	A&E
RNA	Plaster Room
RNC	Occupational Health
RNMH	Extended Role
RNLD	Practice/Treatment Room
HV	District Nursing
Auxiliary	ITU
ODB	Psychiatry
ODA	Learning Difficulty/Disability
ANNP	Theatre
HCA	Recovery
	Paediatrics
CSW	Community Support Worker