6 Sharoe Green Lane, Fulwood, Preston, Lancashire, PR2 8ED,

Tel: 01772 717070

Online Application Form



Post Applied For:
Full Name:
PIN no:
Expiry date:
Address:
Name of next of kin and relationship:
Contact no. and address of NOK:
Date of Birth:
National Insurance Number:
Work permit required:
Yes No 
Telephone Home:
Telephone Work:
Mobile number:
Email:
Nationality/Ethnic Origin:
If you are successful in your application would you require permission to work in the UK?:
yes No 
Do you have a disability?: "
yes No 
Are you aware of NYS Nursing Agency is no smoking policy? :
yes No 
Do you smoke?: yes No  If Yes please give details:
Are you currently employed? :

Yes No 
If yes where:
 
Availability & Access:
Part Time Full Time Desired Hrs per Week Desired started date 
Weekdays:  Yes No    Evenings:  Yes No    Weekends:  Yes No     Night Shift:  Yes No
Can you drive?:
 Yes No
Own transport?:
 Yes No
What locations would you prefer to work in?:
How did you find us?:
Reference:
FULL EMPLOYMENT HISTORY WITH MOST RECENT FIRST
From:

To:
Position held and main duties:
Employer’s Name and Address:
Reason for leaving:
 
From:

To:
Position held and main duties:
Employer’s Name and Address:
Reason for leaving:
 
From:

To:
Position held and main duties:
Employer’s Name and address:
Reason for leaving
 
EDUCATION AND QUALIFICATIONS
From:

To:

School/College/University:
Qualifications:
 
From:

To:

School/College/University:
Qualifications:
 
From:

To:

School/College/University:
Qualifications:
 
HEALTH AND FITNESS TO WORK
AT NYS NURSING WE STRONGLY ADVISE VACCINATION

Have you been vaccinated for the following? If YES please give details
  YES / NO IF YES GIVE DETAILS
TB:  Yes No
Polio:  Yes No
Tetanus:  Yes No
Typhoid:  Yes No
Rubella:  Yes No
Hepatitis B:  Yes No
ARE YOU PHYSICALLY IN GOOD HEALTH AND HAVE YOU SUFFERED FROM/DO YOU SUFFER FROM ANY OF THE FOLLOWING CONDITIONS?
CONDITION YES / NO IF YES GIVE DETAILS
Any Joint Pain:  Yes No
Varicose Veins:  Yes No
Diabetes:  Yes No
Arthritis:  Yes No
Epilepsy or Fits:  Yes No
Heart disease/Problems:  Yes No
Hernia/ Back Problems/Injuries:  Yes No
Vertigo or Dizziness:  Yes No
Mental Illness:  Yes No
Nervous Breakdown:  Yes No
Asthma:  Yes No
Any Drug or Alcohol Dependency:  Yes No
Any Defect of Hearing:  Yes No
Eczema:  Yes No
Skin Problems/Dermatitis:  Yes No
Surgery /Operations:  Yes No
Serious Accident:  Yes No
Tropical Disease:  Yes No
Cancer or Tuberculosis:  Yes No
Have you had a period of two weeks or more absence in the past 12 months:  Yes No
Receive Treatment by A and E of a Hospital in the past 12 month period:  Yes No
Do you smoke cigarettes/tobacco? If so how much per day:  Yes No
Do you drink alcohol? If so how much per day:  Yes No
Have you had more than three spells of Absence in the past 12 months?:  Yes No
High Blood Pressure:  yes No
Kidney problem :  Yes No
 
Experience Assesment

Please indicate below any of the areas that you have experience in. This will help us to find suitable assignments for you.

Adults Learning Disabilities:
Adults Physical Disablement:
Adult Mental Health:
Children Learning Disabilities:
Children Physical Disablement:
Children’s Home:
Community:
Elderly:
Hospitals:
Nurseries:
Schools:
Shelters:
Special Education Schools:
Autism:
Alzheimer’s:
Cancer:
Challenging Behavior:
Diabetes:
Epilepsy:
Hoisting:
Motor Neurone Diseases:
Personal Care:
Practical Care:
Substance Misuse:
Other Please List:
Your present circumstance:
Please read all the following statements carefully and tick the one that applies to you.
A – This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance or taxable Incapacity Benefit or a state or occupational pension. A

OR
B – This is now my only job, but since last 6 April
I have had another job, or have received taxable Jobseeker’s Allowance or Incapacity Benefit. I do not receive a state or occupational pension. B

OR
C – I have another job or receive a state or
occupational pension. C

Student Loans: If you left a course of Higher Education before last 6 April and received your first Student Loan installment on or after 1 September 1998 and you have not fully repaid your student loan, tick box D. (If you are required to repay your Student Loan through your bank or building society account do not tick box D:

EQUAL OPPORTUNITIES

The organisation is committed to a policy of equal opportunities for all and requires all employees to abide by and adhere to this general principle and to the requirements of the Code of Practice laid down by the Equal Opportunities Commission and the Commission for Racial Equality. In particular in this organisation:

  • Discrimination on the grounds of race, colour, ethnic or national origin, religion, class, disability, special needs, on grounds of sex or marital status or membership or non-membership of a trade union will not be practiced or tolerated
  • The organisation expects all employees, of whatever grade or authority, to abide by and adhere to this general    principle.
  • Staff will be promoted, employed and treated fairly on the basis_ of their ability and merits and accordingly to       their suitability and no one will be disadvantaged by a condition or requirement, which is not justified by the genuine needs of their job or of the proposed job
  • The organisation is committed to challenge any form of discrimination it encounters
  • In order to provide equal employment and advancement opportunities to all individuals, employment decisions at the organisation will be based on merit, qualifications and abilities
  • Employees or service users with questions or concerns about any type of discrimination in the organisation are encouraged to bring these issues to the attention of the Nurse Manager or Managing Director.
  • Any breach of this policy should be reported to the Nurse Manager or to a senior, responsible member of organisation staff; breaches will be dealt with through the organisation's disciplinary procedures.

Recruitment of Ex-Offenders
As an organisation using the Criminal Records Bureau (CRB) Disclosure service to assess an applicants' suitability for positions of trust, NYS Nursing Agency complies fully with the CRB Code of Practice and undertakes to treat all applicants for positions fairly. It undertakes not to discriminate unfairly against any subject of a Disclosure on the basis of a conviction or other information revealed.
NYS  Nursing Agency is committed to the fair treatment of its staff, potential staff or users of its services, regardless of race, gender, religion, sexual orientation, responsibilities for dependants, age, physical/mental disability or offending Background.

We do not discriminate against ex-offenders and they will receive fair treatment throughout the recruitment process.

At interview, or in a separate discussion, we ensure that an open and measured discussion takes place on the subject of any offences or other matter that might be relevant to the position. Failure to reveal information that is directly relevant to the position sought could lead to withdrawal of an offer of employment.

We make every subject of a CRB Disclosure aware of the existence of the CRB Code of Practice and make a copy available on request. Having a criminal record will not necessarily bar you from working with NYS Nursing Agency  Ltd. This will depend on the nature of the position and the circumstances and background of your offences.

I confirm that I have read and aware of  this policy.

Have you ever been convicted of or cautioned for a criminal offence?  

If yes , please give details and dates. 

that to the best of my knowledge, all the information provided on this form is correct. I understand that any misrepresentation or withholding of relevant information on this form will be sufficient to invalidate this application and/or terminate any employment which may have begun.

References
Please list below the names, addresses & contact details of 3 referees whom we can approach in confidence to vouch for you. There should be two from your last employer and at least one from an employer in a Care environment (Not Related to You)
Job Reference 1
Name:

Organisation:
Full Address With Postcode:
Relationship to applicant:
 
Job Reference 2
Name:
Organisation:
Full Address With Postcode:
Relationship to applicant:
 
Job Reference 3
Name:
Organisation:
Full Address With Postcode:
Relationship to applicant:
Phone:
 
 
Upload CV:
   

testimonial
  • We are very happy with NYS Nursing, most of the carers who come to my nursing home are lovely and professional. Contact with the co-ordinator in the office is always efficient, very pleasant and they always do their very best to help in all ways possible.

  • Just wanted to say thank you for all your help and support with staff coverage when we were short staffed. Especially qualified nurses who work consistently and knew their roles in the area of work, who in the last few days caring for the people who need it most has been our top priority and we ensure that everything is done to the clients best interests.

  • "NYS have been able to cover shifts that has been an emergency and have got to us within the hour of making the phone call."