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Please complete this form in black ink and complete all sections

Position Applied For

Your Full Name

Data Protection Statement

The personal information (data) collected on this form, and on the attachments, (which includes the collection of
sensitive personal data) are collected for the purposes of recruitment, personnel administration (for new
employees), and monitoring. Unless you direct otherwise (for example in a situation where you would like this
Application kept on file for future vacancies), the Application Forms (and attachments) of unsuccessful applicants
will be destroyed after 6 months. It is the policy of the Agency to protect and keep all personal data collected secure.
All personal data is processed for the purposes of recruitment, and, in the case of successful Applicants, for the
satisfactory administration of their employment, and for no other purpose.

Equality of Opportunity Statement

The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle
that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, color, religion,
marital status, sexual orientation, religion or belief, disability, or offending background.

Which of the following applies to you? Please  as appropriate

RGN □ RMN □ RNLD □ HCA □

NMC pin number Expiry date

LAN Health Care Ltd.

 1.Personal Details
Maiden
Title Surname
name/First name

Previous surnames (if any)

Forenames (in full)

Address

Post Code

Home Work Mobile

Telephone

Email address Nationality

May we contact you at

work Yes □ No □ Please as  appropriate
National
Date of Birth Insurance
number

Next of Kin to be notified in case of emergency: Name

Address

Post Code

Home Work Mobile

Telephone

Relationship to you

LAN Health Care Ltd.

 2. Formal Education and Qualifications
Name of Dates of attendance Course of
School/College/Universit From To study/Qualification
y and Location (s) gained e.g.
Grade
GCSE’s, “A”
Month/Year Month/Year levels, NVQ,
Degree etc.

LAN Health Care Ltd.

 3. Employment History
Please print details of all your employment for a period of at least the last 10 years, to include all nursing agency memberships,
in reverse date order; starting with your present or last position. Please include reasons for gaps.

Name and Address of Dates of employment Position held and brief Reason for leaving/ Last
Employer summary of duties and salary or wage
responsibilities
From To

Month/Year Month/Year

LAN Health Care Ltd.

 4. Training – Manual Handling, BLS, Infection control, First Aid etc. (Please provide
certificates)
Details of training Date Date Courses Taken Attainment
Hospital/Establishment from to

LAN Health Care Ltd.

 H. Your bank account details
Name of bank : Branch name :
Account holder name :
Address :

Postcode :
Sort code : Account number :
I wish to be paid through a Ltd. Company and enclose details. (You will be paid as P.A.Y.E until you provide all

your documentation to LAN Health Care Ltd) □ YES or □ No

I am on P.A.Y. E (Please enclose P45 if we are your main employer) □ YES or □ NO
Read all the following statements carefully and tick the one box that applies to you.
A. This is my first job since 6 April and I have not been receiving taxable Job seeker's Allowance or taxable

Incapacity □ YES or □ No
Benefit or a state or occupational pension □ YES or □ No
B. This is now my only job, but since last 6 April I have had another job, or have received taxable Job seeker's
Allowance, or Incapacity Benefit.

I do not receive a state or occupational pension. □ YES or □ No

C. I have another job or receive a state or occupational pension □ YES or □ No

I. Your next of kin details

Name :
Relationship to you :
Address (including postcode) :

Postcode :
Daytime phone number : Mobile phone number :

LAN Health Care Ltd.

 6. General Information

Do you hold a valid and current British Driver’s License? Yes □ No □

Do you have any endorsements? Yes □ No □
If yes, please give details

Please state which languages you speak, including

an indication for fluency

How did you hear about this agency?

Are you a member of a Union or Professional organization offering indemnity insurance?

Yes □ No □ Please  as appropriate

Body Name : Amount of cover :

Policy Number : Expiry Date :

7. Preference Regarding Work

Please specify which types of work you would prefer. You should tick all appropriate boxes. The service we
give depends on accurate, up to date information. Please keep us informed of all developments in your
career and work preferences.

Positions □
Part time full time □
Type of work Care homes □ Supported living home □ nursing home □
Other, please specify
Long days □ Night Shifts □
Do you have any work commitments? Yes □ No □

Which areas of work do you wish to exclude?

When will you be available to start work?

LAN Health Care Ltd.

 8. Immunizations-proof of immunizations must be provided

Rubella Date
Yes □ No □
Skin test for TB Date
Yes □ No □
BCG Date
Yes □ No □
Tetanus Date
Yes □ No □
Varicella (chickenpox/Vz.Abs) Date
Yes □ No □
Poliomyelitis Date
Yes □ No □
Diphtheria Date
Yes □ No □
Hepatitis B Date of last injection
Booster 1st □ □3 □
2nd rd

Date of last blood Result (titer levels)

IUL

9. References
References are normally taken up for candidates selected for interview. Give details of the names/addresses
of two work-related Referees. One of the Referees should be your current employer, or if presently
unemployed or self-employed, your last employer
Name, Address and Post Code Name, Address and Post Code

Email Email

Telephone Number Telephone Number

Position Position

Relationship to you Relationship to you

May we contact the above person now? May we contact the above person now?
Yes □ No □ Yes □ No □
Please  as appropriate Please  as appropriate

LAN Health Care Ltd.

 10. Confidentiality Declaration
Registration implies acceptance of our code of confidentiality.

In the course of your duties, you may have access to confidential information about your clients. On no account must

information relating to an identifiable client be divulged to anyone other than the manager of the agency. You

should not disclose ANY information to your family, friends or neighbors.

If you are worried by any information, you have obtained and consider that you should talk about it to someone else,

MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER.

Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency

register.

I have read and I understand the above and I agree to abide by the contents therein.

Signature : Date:

LAN Health Care Ltd.

 11. Rehabilitation of Offenders Act
As a general rule, no-one needs answer questions about spent convictions. However, this general rule does not
apply to specified professions, employments and occupations. By virtue of the Rehabilitation of Offenders Act
1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to:

a. any employment or other work which is concerned with the provision of health services and which is of
such a kind as to enable the holder of that employment or the person engaged in that work to have access
to persons in receipt of such services in the course of his normal duties, or
b. any employment or other work which is concerned with the provision of care services to vulnerable
adults and which is of such a kind as to enable the holder of that employment or the person engaged in
that work to have access to vulnerable adults in receipt of such services in the course of his normal
duties.
One or both of the above apply to work with the Agency and covers all occupations.

You are therefore requested to provide details of all convictions, including those which would otherwise be
considered as "spent". All employment applications will be considered carefully, and the disclosure of a conviction
does not imply that this employment application will be rejected.

Records will be checked via the Criminal Records Bureau procedures

I have no convictions □ I have convictions (see note below) □

Please  as appropriate

Note :-
(To protect the confidentiality of this information, please detail convictions on a separate sheet of paper.
Place it in a sealed envelope with your name clearly visible, and headed "Private and Confidential
Criminal Convictions" and attach this to your completed Application Form)

LAN Health Care Ltd.

 Criminal Records – Disclosure Certificate
The Criminal Records Bureau (CRB) have issued a Code of Practice regarding Disclosure Information, a copy of
which is available upon request. A Disclosure Certificate (standard or enhanced) will be requested from the CRB
which will detail all convictions, including those which would otherwise be "spent", as well as details of cautions,
reprimands or final warnings. You will be advised of the type of certificate being requested and asked to give
your approval to this application. The Disclosure Certificate will only be requested in the event that you are
successful in your application for employment.

Asylum and Immigration Act 1996

Under Section 8 of the Asylum and Immigration Act 1996 it is a criminal offence to employ a person aged 16 or
over who is subject to immigration control unless:

 That person has current and valid permission to be in the United Kingdom and that permission does not
prevent him or her from taking the job in question; or
 The person comes into a category specified by the Home Secretary where such employment is allowed.

Any employment offered will be subject to the successful applicant producing appropriate evidence that the
Asylum and Immigration Act is not being contravened.

Are you eligible to work in the UK? Yes □ No □

Please  as appropriate

Personal Declaration

I declare that to the best of my knowledge the above information, and that submitted in any
accompanying documents, is correct, and

 I give permission for any enquiries that need to be made to confirm such matters as qualifications.
Experience and dates of employment, and for the release by other people or organizations of such
information as may be necessary for that purpose.
 I give permission for the processing of the personal data contained in this form for employment purposes
 I understand that any false or misleading information could result in my dismissal.

Signature : Date : ___________________

LAN Health Care Ltd.

 EXPERIENCE (Please write Yes or No)
HOSPITALS
NURSING HOMES
RESIDENTIAL CARE HOMES
LEARNING DISABILITY CENTRE
MENTAL HEALTH
COMMUNITY CARE
OBSERVING CONFIDENTIALITY
REPORTING ACCIDENTS AND INCIDENTS
WRITING SIMPLE REPORT
DENTURE/MOUTH CARE
EYE CARE
HAIR CARE
SHAVING
BED MAKING OCCUPIED/UNOCCUPIED
BED BATHS
BATHING SOMEONE/TOILETING
USE OF BATH AIDS
USE OF COMMODE
CONTINENCE CARE
CATHETER CARE (MALE/FEMALE)
COLOSTOMY/STOMA CARE
PRESSURE AREA CARE
WALKING AIDS
MANUAL HANDLING
USE OF HOISTS AND MANUAL HANDLING EQUIPMENT
NUTRITION
LAUNDRY
COOKING

NAME OF APPLICANT: POSITION APPLIED FOR:

SIGNATURE: DATE:

Please send this application back to

[email protected]

LAN Health Care Ltd.