Application Form | YourNurse

Personal Information

(Please note: Your name should be in full, as appearing on the NMC register and passport)

Title*

First Name*

Surname

Date of Birth*

Home Telephone No*

Mobile No*

Home Address Line 1*

Home Address Line 2

Post Code*

City*

Email*

National Insurance Number*

Next of KIN

Full Name*

Relationship*

Mobile No*

Address Line 1*

Address Line 2

Post Code*

City*

Professional Details

Job Title*

Professional registration Body (NMC/HPC)*

Professional Registration Number*

Date of last appraisal*

Date of next appraisal*

Right to work in the UK

I Confirm I am eligible to work In the UK on the following basis:

Are you an EEA National/ Citizen?*

Yes

No (please answer next question)

Fitness to practice

Have you been or are you currently subject to any fitness to practise proceedings by an appropriate licensing or regulatory body in the UK or any other country ?*

Yes

No

Employment/Education History

Please submit your full Employment/Education history via a copy of your current CV. In your CV mention below things:*

Please supply details of your work history from school to date
Please explain any gaps of 2 weeks or more

(Allowed Type(s): .pdf, .doc, .docx)

Rehabilitation of offenders act

Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations, which might lead to a conviction, an order binding you over or a caution in the UK or any other country?*

Yes

No

Disclosure and Barring service

All public and private organisations request that an Enhanced Disclosure be obtained for all healthcare personnel acquired from the Disclosure and Barring Service or Disclosure Scotland through Your Nurse

Do you have an Enhanced Disclosure and Barring Service certificate*

Yes

No

Update service*

Yes

No

Professional References

Please provide names and contact details of professional referees from your most recent employment, which must cover the last 5 years of employment/education. Referees must be working in senior position to yourself

Full Name*

Position*

Email*

Mobile No*

Organisation Address Line 1*

Organisation Address Line 2*

Relationship*

Date of Employment*

GDPR declaration

In accordance with the new general data protection regulations (GDPR) we are asking you to sign this to provide consent for Your Nurse to collect and retain your information on our system.

Declaration

The Working Time Regulations 1998 require Your Nurse to limit your average weekly working time to 48 hours unless you agree with Your Nurse that the limit shall not apply to you

Yes (I agree to limit my working week to no more than 48 hours)

No (I disagree to limit my working week to no more than 48 hours)

Signature*