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ANA Nursing Application Form

Please fill out all fields correctly according to your understanding.

Personal Information:




Yes
No

Yes
No

Yes
No

Yes
No

Elementary proficiency
Limited working proficiency
Professional working proficiency
Full professional proficiency
Native or bilingual proficiency

Yes
No

Yes
No

Full Employment list

Please note a full employment history must be provided, or your umemployment history since leaving full time education if less than 10 years.
Please explain any gaps in your work history.
(You may as many rows as necessary)

  From (mm/yyyy) To (mm/yyyy) Name and address of Employer Reasons for leaving

Educational Qualifications

  Qualification Name and address of Institute Date qualification attained

Details of skills/experience

References

Please provide the names of at least two people, on of whom MUST be your present or
last employer, who may be asked for a reference. All applications for references will be made
in the strictest confidence after first having obtained your permission.

Reference 1:*

Employer

Reference 2:

School/College/Employer/Character

Reference 3:

School/College/Employer/Character

Disclosure of Criminal Convictions

(Spent and Unspent)

It is the policy of ANA Nursing to require all applicants to disclose criminal convictions, cautions and any other dealings that may have had at any time
with the Police

You are required to include convictions, which may be "spent" under the Rehabilitation of Offenders Act 1974. This is because the job you are applying for
is covered by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and 1986. Both "spent" and "unspent" criminal convictions must therefore be disclosed

The information you provide will be treated as strictly confidential and will be considered for appointment for which you are applying.
Disclosure and Barring Service checks will show anything which the Chief Constable feels may be relevant.

Disclosure of any information does not necessarily mean that you will not be considered for an appoitment.
The Company will have regard to the ACAS Code of Guidance and a main consideration will be whether the offence is one which would make an apllicant usuitable
for the type of work to be done. Enter any information is the space provided. If you have no information that you believe is relevant, please enter "none".

  Information Date Outcome

Pension


Yes
No

Yes
No

Yes
No

Declaration

I confirm that I have read and understood this document and the information I have provided is complete and true and that I understand that making a false statement could be a criminal offence*
I consent to ANA Nursing checking the details I have provided in support to this application form agaisnt various data sources in order to verifiy my identitiy and process this registration.
these details may be recorded and used to assist other organisations for identitiy verification such as a DBS*
I understand that the completion of this form does not guarantee employment and that any offer of employment made is subject to the receipt of satisfactory references and an Enhanced Disclosure and Barring Service Check*
I understand that ANA Nursing is an Equal opportunities employer and that an offending record or medical condition is not necessariliy a bar to employment*
I give consent to my personal information being shared as described above and I further consent to my personal file being made to the Care Quality Commission, Skills for Care (the workforce development organisation for social care) and Local Authorities Social Services*


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