Dear Applicant Date as postmarked Please find enclosed an application pack as requested. Upon completion please return to our Eastbourne Office, together with two passport sized photographs (or photos can be provided at a later date). Once your completed application is received all references will be sought prior to interview. Premier Care Nursing Agency requires two references from current/previous employers at the work addresses and one personal/character reference, preferably from a colleague/co-worker (who must not already be employed by this agency). If only one work reference contact details can be given as long if it is for a valid reason then that will suffice. Please ensure that you give full names, addresses and post codes. Although you can commence your employment with another employer s DBS it is company policy that each member of staff does in due course obtain an Enhanced DBS through Premier Care. The current cost of 49.99 will have to be met by you. Alternatively, should you be part of the online DBS Registration, Premier Care is happy to proceed, with your permission, to carry out an online status check instead of completion of a new Disclosure (at no cost to yourself). And because as an applicant you might be aware of others who might consider joining Premier Care you should be aware of that even as another applicant you do qualify for our REWARDS FOR RECRUITMENT scheme. For any Carer, Support or Nursery Worker (with previous experience) that you introduce you be rewarded with 50 for a Nurse / RMN and 30 for all other staff. The only qualification is that the applicant completes 37.5 hours before you receive the payment. To ensure you are rewarded for introducing someone do ask them to write your name on the last page of the application form where it says how did you hear about premier care, but we are not trying to avoid paying this so by all means call or text us the name of the applicant just in case they forget to do this, but this notification must be received BEFORE their application form arrives. You can receive as many of these payments as you introduce applicants so please do encourage any one that you think might wish to join us. Do assure them that there is plenty of work, great rates of pay for Nurses and Care staff and we are now the number one preferred supplier to East Sussex NHS as well as ESCC owned homes. At your interview you will be asked to provide identification such as Passport, driving licence, NI Number, PIN Number, birth certificate, marriage certificate, current DBS, proof of address and all relevant care sector training certificates. Please return this form as soon as possible either by post to the EASTBOURNE office or by email to eastbourne@premiercare.uk.com. We hope to see you soon. Yours faithfully Premier Care
Office use Ref. No: Attach 2 Photographs Application for Registered Nurse Title Surname Address First name Middle name Maiden or Previous name Home Tel. No: Mobile Tel No: E-mail Address Date of Birth (Payroll Requirement) NI Number: Postcode Where did you hear about us? Home Office Papers Where Applicable Details of indefinite leave / student visa /working holiday Please note: Work Permit Holders can not work for nursing / employment agencies Public Transport Yes No Car Owner & Driver Yes No Pin Number Pin Expiry Date Part of Register
Education, training & vocational courses undertaken. Most recent first. List all. Names & addresses of universities, colleges & schools attended Courses & subjects studied From Year To Year Qualification Grades Achieved
Employment history since leaving school. Include adaptation nurse training. Most recent first. List All. Explain all gaps in employment. Name & Address Of Employer Job Title & Department Hourly rate of pay From m/y To m/y Reason for leaving Areas you have recent experience with & can work in
Circle where appropriate HDU Neurology Psychiatric - adult Surgical ward Oncology Nursing Homes ITU Theatre Psychiatric - Child Medical Ward Clinic Outpatient NHS CCU MAU Midwifery Special care baby Pregnancy Gynae. Childrens ward Diabetic Endocrin. Day Surgery Rehab. Stroke Private Cardiac Ortho. Thoracic A&E Gastro- Enterology ENT Max. Fac. Urology Opthalmol Respirat Other:. Name, Address & Telephone Number of GP Dr Tel No: Address: Name & Address of Next of Kin in case of emergency Name Relationship Address Home Address Work Home Tel. No: Mobile Tel. No: Work Tel. No
Two references; one must be from your current employer or most recent employer if currently unemployed. To be sent to the work addresses. One personal / character reference from someone who has known you for at least one year; preferably a work colleague. Not a relative. Work Reference 1 Name Work Address Incl. postcode Occupation Position referee employed as Work Tel. No: And Fax No: Organisation Company name Work Reference 2 Name Work Address Incl. postcode Occupation Position referee employed as Work Tel. No: And Fax No: Organisation Company name Character reference 3 Name Work Address Incl. postcode Occupation Position referee employed as Work Tel. No: And Fax No: Organisation Company name
Disclosure of information Due to the nature of the work concerned this post is exempt from provision of section 4(2) of the Rehabilitation of Offenders Act 1974. You are not entitled to withhold information about convictions, bind over orders, fixed penalty notices or cautions which for other purposes are spent under the provisions of the Act. Any such information given will be strictly confidential & will be considered only in relation to your application for the post. This application will be returned if this section is incomplete and failure to disclose convictions, penalty notices, bind over orders or cautions will result in disqualification / dismissal. Canvassing a member of management & the provision of false information will also result in disqualification / dismissal. Have you been convicted of a criminal offence, including driving offences? Details & Dates Yes No Have you been cautioned by the Nursing & Midwifery Council (NMC formerly the UKCC) or suspended at any time from the Register? Details & Dates Yes No Declaration I certify that the above information is true & accurate. If required I am willing to undergo a medical assessment to confirm my fitness for employment in the post for which I am applying. Name: Signature: Date: Licensed for the supply of Nurses by the CQC. Nine to Five (Sussex) Ltd. Company Secretary M. Gibby. Registered Office: 33 Station Rd, Bexhill on Sea, E. Sussex, TN40 1RG Co. Reg. No: 2946716 Licence No: SE15717 VAT No: 571 7038 39
Vaccinations It is strongly recommended you have the following vaccinations. Consult your GP or Practice Nurse. Have you had the following vaccinations? Tetanus (3 during childhood given with other vaccine injections for diphtheria, polio, whooping cough, Hib) Course 1 DtaP/IPV/Hib Yes No Date: Course 2 dtap/ipv or DtaP/IPV Yes No Date: Course 3 Td/IPV Yes No Date: Tetanus Booster (every 10 years from 18yrs) Yes No Date: Heaf / Mantoux (TB skin test) Yes positive Date: Yes negative Date: No Tuberculosis (BCG vaccine 10-14yrs) Yes No Date: Hepatitis A (2 doses 6-12 months apart, every 10 years) Yes Course 1 Date: Course 2 Date: No Hepatitis B (3 doses over 6 months) Yes No Course 1 Date: Course 2 Date: Course 3 Date: Hepatitis B Antibody Test Date: Hepatitis B Booster (every 5 years) Yes No Date: Measles / Mumps / Rubella (MMR) Yes No Date: Polio Booster Yes No Date: Rubella (German Measles) Yes No Date: Rubella antibody test Yes No Date: Meningitis C (20-24 yrs) Yes No Date: Varicella (aka Chicken Pox, 2 doses 13yrs+) Yes No Course 1 Date: Course 2 Date: Varicella antibody test Yes No Date: Flu vaccine (yearly) Yes No Date: I declare that all foregoing statements are true & complete to the best of my knowledge & belief. Signature: Date:
Job Description Registered Nurse Job Title: Qualification: Accountable to: Report to: Responsibilities: Agency Registered Nurse First or Second Level NMC Registered Nurse. Nurse Manager Nurse Manager / Local Branch Manager. Within the remit of your capabilities assess, plan & Implement the highest standards of holistic nursing for the clients in your care. Familiarise yourself with and adhere to the policies and procedures of the establishment you are working in, to include Health and Safety, Fire Safety and Uniform Policy. Ensure privacy and dignity for all clients in your care. Maintain client confidentiality at all times. Assist in the supervision & training of other members of staff. Maintain appropriate, accurate & legible records. Adhere to the NMC Guidelines for records and record keeping document. Familiarise yourself with the whistle blowing policy of each establishment and prevent abuse. Adhere to NMC Practitioner-client relationships and the prevention of abuse document. Work as a team member and communicate effectively with client and colleagues to maintain and improve standards of care. Familiarise yourself with the medication policy of each establishment and adhere to the NMC Guidelines for the administration of medication document. name Sign date
Equal Opportunities Monitoring Form for Applicants To monitor and develop our Equal Opportunities strategy please complete the details below in full. The information you provide will not be used during the application process. The form will be placed in a separate file and kept in accordance with the Data Protection Act. Date Form completed: Male Female 18 24 25 34 35 49 50 59 60+ Yes No Gender Age group Do you consider yourself to have a disability? If answered yes please provide details:
Please tick the boxes that describe your ethnic and national groups Ethnic Group White Mixed White & Black Caribbean White & Black African White & Asian Other Mixed background please specify: Asian Indian Pakistani Bangladeshi Other Asian background please specify: Black Caribbean African Other Black background please specify: Chinese Other ethnic group please specify: English Scottish Welsh Irish British Other please specify: National Group
PREMIER CARE NURSING AGENCY When asked to attend an interview please make sure that you bring with you the following, original documents, copies are not acceptable. 1. P45 should this be your main form of employment 2. Two passport sized photographs (if not already sent with your completed application form). 3. Three forms of identification; which includes photographic identification. Birth Certificate Marriage Certificate Passport Driving Licence; both photo card and paper counterpart 4. All documentation adhering to any name changes (adoption papers, marriage certificate, deed poll (name change) documents etc) month and year to be disclosed. 5. Three recent bills with your current name and address on them Mobile phone bill is not acceptable 6. National Insurance Number 7. Moving & Handling Certificate 8. All other certificates / qualifications 9. Home Office Papers (if applicable) 10. Valid Nursing PIN Number (if applicable) 11. Bank or building Society Account details 12. Uniform size including 25.00 deposit per uniform (cash or cheque). 13. DBS (CRB) Payment (cash or cheque)