Your Name Ms Miss Mrs Mr

Date of Birth

Gender Select Male Female

Are you a British or EU passport holder Select Yes No

Address

Contact Details

National Insurance Number

Next of Kin

Date attended Are you a student nurse Select Yes No College/Qualifications obtained

NMC PIN Number Expiry Date Date of Qualification

Please cover full employment history with any gaps explained. Please provide us with the Name and address of employer, your position held, your start and end date and the reason for leaving.Please start with your current employment first.

Do you or have suffered from any health issue (physical or mental) that would effect your ability to work for Rapid Response Secure Ambulance Ltd? Select Yes No Are you currently receiving any medical treatment or counselling? Select Yes No Are you taking any prescribed medication? Select Yes No Have you had any major illness in the last year Select Yes No Are you registered as disabled? Select Yes No If you have answered YES to any of the above questions please give further details here

Do you, or have you ever suffered from any of the following?

Epilepsy Select Yes No Diabetes Select Yes No Tuberculosis Select Yes No Hepatitis B Select Yes No Depression/mental illness Select Yes No Back problems Select Yes No Communicable disease Select Yes No Chicken Pox Select Yes No

Have you had any of the following immunisations

Tripple vaccination as a child (Diptheria/Tetanus/Whooping cough) Select Yes No NMR (Rubella/Measles/Mumps) Select Yes No Hepatitis B (If yes please give dates below) Select Yes No Please give dates for Course 1, 2 and 3 as well as Boosters

REFEREE 1

Please give work address only

Full Name Title Tel Email How do you know this referee? Are you happy for us to contact this referee prior to interview? Select Yes No

REFEREE 2

Please give work address only

Full Name Title Tel Email How do you know this referee? Are you happy for us to contact this referee prior to interview? Select Yes No

Declaration

DBS No. Have you ever been convicted of a criminal offense Select Yes No Please give further details

Due to the nature of the work which is offered by Rapid Response Secure Ambulance Ltd, this post is exempt from the provisions of section 4(2) of the Rehabilitation of offenders act (1974) (Exemptions) (Amendments) order 1986. This means that applicants cannot withhold information about convictions (whether or not the have been 'Spent' under the Act). PLEASE NOTE A conviction does not automatically stop you from registering.

Do you agree to a Police Check being carried out if necessary? Select Yes No
Confirmation
I confirm that the information on this form is correct and complete to the best of my knowledge
Date

The General Data protection Regulation (GDPR) (EU) 2016/679

All information supplied by you will be held in confidence by Rapid Response Secure Ambulance Ltd. Records will be retained electronically and on personal file in accordance with best practice and the requirements of the GDPR at which time may be subject to audit. Your data may be required to be seen by our Stakeholders, Clients, Auditors, Managers, HR Advisors, Occupational Health as part of Compliance Requirements without your explicit consent. You have the right of erasure (the right to be forgotten), withdrawal of consent and refusal of consent without detriment. The only exceptions to this may be a court order for release of records in judicial dispute or where there is a public responsibility obligation.

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