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Position You're Applying For
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How did you learn about this vacancy?*
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About You:
Title
Mr
Mrs
Ms
Miss
Doctor
Other (please specify)
Surname
Other Names
Address
Telephone Number
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Email
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National Insurance Number
Are you 18+ years of age?
Yes
No
Do you require a work permit to be employed in the UK?
Yes
No
Next of Kin Contact Details:
Name
Relationship
Tel Number
Address
Work History:
Current/Last Employer
Start & End Date of Employment
Employer Address
Position Held
Reason for leaving, if applicable
Notice period, if applicable
Final Grade/Salary
Qualifications:
Professional Qualifications held:
Professional Registration(s):
NMC Pin (if applicable)
Expiry Date:
Education:
University / College
Qualifications Obtained
Date
Your Application:
Your Experience
Your Statement
Outside Interests
Field Name
Disability Discrimination Act 1995
Do you consider yourself to be disabled under the ‘Disability Discrimination Act’?
Yes
No
References:
Referee 1:
MUST be Current or Most Recent Employer
Field Name
Full Name
Job Title
Organization
Address
Postcode
Tel. No
Email
Please state if we may obtain this reference prior to interview.
Yes
No
Referee 2:
Title (Mr, Mrs etc)
Job Title
Organization
Address
Postcode
Tel. No
Email
Please state if we may obtain this reference prior to interview.
Yes
No
Interview Arrangements
Special Arrangements Required?
Rehabilitation of Offenders Act 1974
Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act (Exemptions) 1973. Applicants are, therefore, not entitled to withhold any information about convictions, for which other purposes, are ‘spent’ under the provisions of the Act. In the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be treated in the strictest confidence and will only be considered in relation to posts for which the order applies.
Do you have any criminal convictions to disclose? (delete as applicable)
Yes
No
If YES, please give details:
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0161 549 8271
07500 937 777
admin@keromina.co.uk
Northgate Lane, Oldham, OL1 4RU
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