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YOUR APPLICATION PACK Step 1 of 6

PRIMARY COMPANY YOU WISH TO JOIN:

I agree that the information I provide in this application pack can be used by both sister companies: Wimborne Nursing Agency and HMR Medical & Nursing Service. The reason for this is to provide me with more opportunity and diversification in the work I can potentially be offered.

YOUR PERSONAL DETAILS Step 2 of 6

NEXT OF KIN DETAILS

NATIONALITY DETAILS

WNA / HMR do not employ any nurse / carer requiring a work permit or with limited leave to remain in the UK.

NMC DETAILS

TRANSPORT DETAILS

YOUR EMPLOYMENT HISTORY Step 3 of 6

Date from mm/yy Date to mm/yy Employer’s name and address Position Reason for leaving

YOUR PROFESSIONAL CONDUCT

Have there been any proceedings of medical negligence of professional misconduct against you and have you ever been suspended or dismissed

YOUR REFERENCE DETAILS

YOUR CLINICAL EXPERIENCE Step 4 of 6

Please check box in the relevant experience / years you have in each field, or leave blank if not applicable.

GENERAL EXPERIENCE 0-12 months 1 year + GENERAL EXPERIENCE 0-12 months 1 year +
Medicine
Learning Disabilities
Surgical
Domicilary Care
Mental Health
Nursing Homes
Prisons
Observation Records
HCA ONLY 0-12 months 1 year + HCA ONLY 0-12 months 1 year +
Urinalysis
Toileting
BM Testing (Diabetes)
Mobility
Personal Hygiene
Nutrition
Others
Record Keeping
HOSPITAL EXPERIENCE 0-12 months 1 year + HOSPITAL EXPERIENCE 0-12 months 1 year +
A&E
Paediatrics A&E
Cardiac
Paediatrics
Chemotherapy
Palliative Care
Clinics
PCIU
Community
Plastic Surgery
Coronary Care Unit
Radiology
Diagnostic Imaging X-ray
Recovery
Dialysis
Renal
Elderly Care
SCBU
Endoscopy
Surgical
General wards
Theatres
Gynaecology
Triage
Health Visitor
Urology
High Dependency Unit
NICU
Walk in Centres
Nurse Practitioner
ITU - Intensive Care Unit
Occupational Health
Learning Disabilities
ODP
Medical Health
Oncology
Mental Health
Orthopaedics
Midwifery
Neonatal

YOUR PAYE / LTD BANK ACCOUNT DETAILS Step 5 of 6

We pay wages directly into a bank account.

BANK DETAILS

READ ALL THE FOLLOWING STATEMENTS CAREFULLY AND CHECK THE BOX THAT APPLIES TO YOU.

I wish to be paid trought a Ltd. Company and enclose details. (You will be paid as P.A.Y.E. until you provide all your documentation to WNA / HMR)

I am on P.A.Y.E. (Please enclose P45 if we are your main employer)

PLEASE NOTE THAT WITHOUT THE CORRECT DETAILS YOU WILL NOT BE PAID ON TIME AND THIS SHEET WILL BE RETURNED BACK TO YOU.

AVAILABILITY QUESTIONNAIRE Step 6 of 6

5. Please detail dates of any time off or planned holiday.

6. Please choose your preferences for establishments.

Hospitals Community Nursing Homes Prisons
South
South East
South West
Midlands
North

Other / specific locations