PRESENT OR MOST RECENT POST

Job Title:

Grade:

Anntrual Salary:

Date of Starting Grade:

Employer:

Date of Employment

From:

To:

Reason for Leaving (if applicable):

Role Purpose/Summary of Responsibilities:

Employement History

Recent Job Title:	Employer:	Date From:	Date To:

Referees

Your referees will include your current (or most recent) employer. Please identify below the person in your organisation (e.g. your direct line manager) who is authorised to confirm your employment and the details given in your application. Please identify a second referee who may have closer knowledge of your skills, knowledge, and abilities, and who may offer
opinion on your suitability for the post. You should not use family members or friends. You should use referees from two separate employers. Our pre-employment screening also includes, where appropriate, health and fitness for work, criminal records, qualifications, and professional registration.

Name 1:

Designation:

Telephone:

Email:

Address:

Post Code:

Name 2:

Designation:

Telephone:

Email:

Address:

Post Code:

Disability

The Disability Discrimination Act 1995 and Amended Regulations 2005 defines disability as follows: “any physical or mental impairment which has a substantial adverse effect on a person’s ability to carry out normal day to day activities.” ScotNursing is “Positive About Disabled People”, and as such we provide job opportunities for people with disabilities people.

Please specify any special requirements if attending for interview, e.g. Induction Loop, Wheelchair Access, Signer:

Driving Licence

Do you have a current UK driving licence?
YesNo

If "Yes" for which type of vehicle?

STATEMENT IN SUPPORT OF APPLICATION – Please tell us your personal qualities and attributes, experience, and any major achievements and show how they match thoseneeded for working with us:

Immunisation

Immunisation	Certification Date	Notes
Hep B Mandatory		You will require to provide evidence of viral titre above 100.
Rubella		You will require to provide evidence of antibibodies.
Tuberculosis		You will require to provide certification of BCG Star Check or Heaf/Mantoux result of 2-4.
Varicella		You can self declare having chicken pox or shingles. If not you require to provide evidence of blood results.

Our Occupational Health team can assist with the above if required.

Bank Details for Wages

Name of Account Holder:

National Insurance No:

Name of Bank:

Address of Bank:

Postcode:

Sort Code:

Account No:

Please read the following statements. You will be asked to sign a declaration if you areappointed.

Date:

EQUAL OPPORTUNITIES MONITORING

We want to ensure that our job opportunities are open to all. The only way that we can ensure that there is an equal opportunity is to monitor applications we receive and compare the profile of people who apply with those appointed. Therefore this form asks you for your ethnic origin, gender, disability, religion, sexuality, and age. The information you provide in this form is confidential and is not used in the selection process.

You are:
MaleFemale

What is your age?

You are:
SingleMarriedDivorcedWidowed

Do you have a physical or mental health condition or disability that: