Application Form

AN EQUAL OPPORTUNITIES EMPLOYER

NOTES: Candidate Reference Number

CVs will not be accepted

Canvassing will disqualify Ref No: Date of Interview ( )
Only applications containing all the information
Job Title : Nurse Band 5 (Adult)
which has been sought will be considered
You are strongly encouraged to complete the Equal
Opportunities monitoring form at the back of this
application form.
Please complete in Black Ink

For administrative purposes please indicate planned holiday arrangements:

We are under no obligation to take account of your holiday arrangements

Personal Details
Title (Mr, Mrs, Miss, Ms, Dr): First Name (s)

Surname: Previous Surname

Permanent Residence Temporary Residence (if different)

Address Address

Country Country

Preferred Address for Contact

Permanent Residence Temporary Residence
(please tick)

Communication Data please note correspondence is generally by Email

Email Address:

Mobile
Private Telephone Number
Number
Preferred Number for
Private Number Mobile Number
Contact (please tick)
References

Please name two suitable referees (not relatives), at least one of whom should have knowledge of your present or most
recent work as your line manager. If you have worked in the Healthcare setting at least one referee must be from a
Healthcare Professional in a line manager role (if you have ever worked in the NHS / HSC we will also reserve the right to
obtain a reference from this setting).

Title (Mr, Mrs, Miss, Ms, Dr): Title (Mr, Mrs, Miss, Ms, Dr):

Name: Name:

Occupation Occupation:
:
Address: Address:

Telephone Telephone
No: No:
Email: Email:

EDUCATION Please state all School or College level examinations completed

Subjects Passed Examining Body Level Attained Grade Year

PROFESSIONAL QUALIFICATIONS (e.g. Nursing qualifications)

Name of Name of Qualification Date Obtained Professional Expiry Date of

Professional Body Registration
Body Registration
Number

EMPLOYMENT HISTORY PRESENT POST

Employer Name: Period of Notice:

Employer Address: Salary/Wage:

Job Dept/Location:

Start Date:

Job Title: Reason for Leaving:

Principal Duties of Present Post:

Employee Status: Permanent Temporary Agency

 EMPLOYMENT HISTORY PREVIOUS POSTS

Please list all your previous posts beginning with the most recent including periods out of employment and any training.
Period of Employment
Name and Address
Job Title / Reason for
of Employer Duties
Job Role From To Leaving
(dd/mm/yy) (dd/mm/yy)

If you have any gaps in your career history, please include and explain these in the box below ,
ADDITIONAL INFORMATION

Please include any other information which may be relevant to this application such as a personal statement as to why you wish to
work as a Nurse in Northern Ireland.

PERSONAL DECLARATION
1. I declare that all the foregoing statements are true, complete and accurate
2. I understand that if I give wrong information or leave out important information I could be dismissed if I take up
this job
3. I understand that to take up this job I must have satisfactory references, health assessment and Access NI
checks
4. I understand that I will be asked to show some formal identification and evidence of qualifications
5. I confirm that as far as I know there are no medical reasons which would stop me from carrying out the duties
of this job
6. I agree to you making any necessary enquiries during the recruitment and selection process
7. I understand that canvassing will disqualify me from the selection process for this job
8. I consent to the information I have provided being used within the context of the Data Protection Act 1998 and
understand that my application will be submitted to and processed by TTM Healthcare on behalf of the HSC
to which I am applying but will also be accessible to the HSC Trust (s) during the selection process. I also
understand that if I am successful this application form will be provided to HSC Recruitment Shared Services
Centre for electronic recording as well as the HSC Trust to which I am appointed to support the creation of the
employment relationship and that information herein will be held both in hard copy and electronically.

Your Signature ______________________________________ Date ______________

This page is intended to be blank
 Candidate Reference Number

For Office Use Only:

EQUAL OPPORTUNITIES MONITORING

This organisation is committed to equality of opportunity for all staff and job applicants. The Trust selects those
suitable for employment and advancement solely on the basis of merit and is also monitoring its activities to
ensure that its equal opportunities policy is effectively implemented.
Section 75 of the Northern Ireland Act 1998 requires us to promote equality of opportunity on the basis of all
nine categories. To assist in this monitoring process it is necessary to ask you a number of questions.

(1) Date of Birth: / /

(2) Sex: Male Female

(3) Marital Status: Single Married / Civil Partnership Other

(4) Community Background:

To demonstrate our commitment to equality of opportunity in employment we need to monitor the community
background of applicants and employees, as required by the Fair Employment and Treatment (NI) Order 1998.
We therefore ask you to indicate your community background by ticking the appropriate box below. Please
note that it is an offence under the Fair Employment and Treatment (NI) Order 1998 to give false
information to the Trust.

a) I am a member of the Protestant community

b) I am a member of the Roman Catholic community

c) I am a neither a member of the Protestant nor Roman Catholic community

d) We recognise that there may be occasions where religious belief differs from perceived community
Background. In order that our records are correct, we therefore would ask you to indicate your religious
belief by ticking one box.

Muslim Hindu Sikh Jewish Buddhist Christian

None Other (Please Specify) _____________________

(5) To which of these ethnic groups do you consider you belong:

White Black African Bangladeshi

Chinese Irish Traveller Pakistani
Indian Black Caribbean Mixed Ethnic Group
Filipino Black Other
Any Other Ethnic Group (please specify) _________________________________________

Please also specify your nationality:

(e.g. Latvian, Lithuanian, Polish, British, Scottish, Welsh, Irish, Portuguese etc.)
_____________________________________________________
(6) Do you have caring responsibilities for: (Tick each box that applies to your circumstances)

A child (or children) A person(s) with a disability

A dependent older person None of the above

(7) Disability:

The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has
a substantial and long-term effect on a person's ability to carry out normal day-to-day activities.
"Normal day-to-day activities" listed in the Act are mobility; manual dexterity; physical co-ordination; continence;
ability to lift, carry or otherwise move everyday objects; speech, hearing or eyesight; memory or ability to
concentrate, learn or understand; or perception of the risk of physical danger.

(If you take medication, treatment or have a prosthesis to manage your condition, would you consider
that you had a disability if you were without these? If so, you should answer yes below).

Having read this definition, do you consider yourself as having a disability?

Yes No
If yes, please indicate which type of impairment(s) apply to you. (Please tick all that apply to you)

Physical Impairment, such as difficulty using arms or, mobility requiring wheelchair or crutches
Sensory Impairment, such as blind/visual impairment or deaf/hearing impairment
Mental Health condition, such as depression or schizophrenia
Learning disability, such as Downs Syndrome, Dyslexia or Cognitive Impairment such as Autism
Long standing illness, such as cancer, HIV, diabetes, chronic heart disease or epilepsy
Other_________________________________________________________________________

(8) Sexual Orientation:

My Sexual Orientation is towards someone:

Of the opposite sex Of the same sex and of the opposite sex

Of the same sex I do not wish to answer

(9) Political Opinion:

This question has been removed as it is not relevant on International Recruitment trips

(10) Are you currently an employee of the organisation to which you are applying (excludes agency
workers)?
Yes No

Access to this information will be strictly controlled. Monitoring will involve the use of statistical summaries of
information in which the identities of individuals will not appear. Whilst the Trust will treat the information given
in this monitoring slip as confidential, staff are advised that legal processes may require the Trust to disclose
the information given to certain statutory bodies, and, in some circumstances, open Tribunal. Employees
should complete the form in the knowledge that it will be processed in line with requirements of the Data
Protection Act 1998.

The information will subsequently be transferred to the monitoring system operation by the Trust. There it will
be strictly controlled in accordance with an agreed Code of Practice.