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APPLICATION-FORM
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2024-07-01T07:15:13+00:00
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Current Driving Licence:
Yes
No
Do you have a regular use of a car?
Yes
No
EDUCATION AND QUALIFICATIONS
*
QUALIFICATIONS
School
QUALIFICATIONS
School
EDUCATION AND QUALIFICATIONS
COLLEGE EDUCATION
QUALIFICATIONS
COLLEGE
Result
Exams passed
Awaiting
EDUCATION AND QUALIFICATIONS
UNIVERSITY EDUCATION
QUALIFICATIONS
UNIVERSITY
Result
Exams passed
Awaiting
PAST EMPLOYMENT & EXPERIENCE
EMPLOYMENT RECORD
Please give length of experience of the following: (Staff Nurses Only
EMPLOYMENT RECORD
Speciality
ITU
CCU
Theatres
A&E
Paediatric
Psychiatry
Learning Disabilities
Speciality
Gynae
Obstetrics
Renal
District Nursing
Occupational Health
Care of the Elderly
Other
Have you ever worked for?
NHS
GP Practice
Nursing Homes
Nursing Homes
Private Sector
FURTHER INFORMATION
Please give any further information in support of your application you think is relevant
State of health (Delete not Applicable) Are you suffering from, receiving treatment for or anticipating any surgical intervention for any medical condition that may affect your ability to carry out normal daily duties? If yes, please supply details separately
Yes
No
Rehabilitation of Offenders Act 1974 – Exemption from (s) 4 (2)
This employment is exempted from the above Act and employees are not therefore entitled to withhold information about spent convictions. In the event of your ever having been convicted of any offence by a court of law, please give details of the offences with dates. Have you had any convictions? Yes No If your answer is yes, please give details below; continue on a separate sheet if necessary.
Yes
No
HEALTH SCREENING (Care workers and Nurses only)
Please give last date of immunisation for the following:
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NATIONALITY
Yes
No
COMMUNICATION
Yes
No
Yes
No
MEDICAL HEALTH DECLARATION
Do you have any medical condition that we should know about in relation to your work?
Yes
NO
Please explain
TIMES AVAILABLE
Morning
Afternoon
Night
Flexible hours
Week
Mon
Tue
Wed
Thus
Fri
sat
Are you able to work flexible hours?
Yes
NO
REFERENCES
Yes
No
Yes
NO
GP’S Details
Name
*
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APPLICANTS’ DECLARATION
I confirm that I am over 18 years of age.I declare that all the information I have given is true and I understand that any false or misleading information may result in my removal from Alpine Care staff register.I agree that premiums for professional negligence indemnity insurance and training may be deducted from my fees.Under no circumstances must I apply to work for Alpine Care clients or homes during my working time with Alpine Care and Twelve months after my resignation as this will jeopardise the employment relationship and agreement between the two companies.I agree to abide by the above and the conditions of engagement.
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