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Registration Form
Place of Interview
Full Name of Interviewer
Interviewer Email Address
Date
Applicant Full Name
Applicant Maiden Name
Date of Birth
Marital Status
Single
Married
Divorced
Widowed
Do you hold a driving license valid for use within the UK?
Yes
No
National Insurance Number
I confirm that I have received and read the Key Information Document
Yes
I confirm that Ever Nurse Group have my permission to request and obtain copies of payslips from my employer/ umbrella company/ personal service company and have my permission to make this available to third parties
I Agree
I understand that any personal data held by Ever Nurse is liable to be inspected by the Care Standards Commission and/or any other authorised 3rd party including for any audits. Please select below if you do/do not agree for your personal data to be made available to any 3rd party without direct supervision from a member of staff from Ever nurse or myself being present
I Agree
I agree to give Ever Nurse Recruitment permission carry out online DBS checks both annually or as required
I Agree
I confirm that Ever Nurse Group have my permission to generate and complete my share code check for my right to work
I Agree
I confirm that I have received, read, and understood the contents of the Ever Nurse Locum Handbook and agree to comply with its guidance. I have also read and understood the terms and conditions of engagement with Ever Nurse.
I understand that my Ever Nurse ID badge must be worn visibly at all times while on assignment, and I agree to return it if I leave the organisation.
I acknowledge that all patient records must be handled in strict confidence in accordance with the Data Protection Act 2018 and GDPR. I further agree not to disclose any confidential information to third parties without prior written consent.
I Confirm
I agree for Ever Nurse to complete checks on my professional registration licence where required.
I Agree
I agree that I will maintain my Right to Work status and inform Ever Nurse should this change at any stage of my registration.
I Agree
I agree that I will adhere to the restrictions of my Right to Work status where applicable.
(
I Agree
I agree to inform Ever Nurse should I be subject to any investigation or Fitness to Practice whilst registered.
I Agree
Grade/Band
Specialty
Next of Kin Full Name
Relationship
Contact Number
Address
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Country
Do you hold a British Passport?
Yes
No
Evidence of all passports and visas are required. Please enclose photocopies with this application form and make sure you bring the originals to your interview. To work in the NHS you will be expected to communicate proficiently in English and this will be assessed at your interview.
Passport Number
Passport Expiry Date
Working Holiday Visa
Yes
UK Residency Visa
Yes
Student Visa
Yes
Working Permit
Yes
Should you hold any other Visa or residency permit, please provide the information below:
Current Address
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Country
Mobile Phone
Home Phone
Work Phone
Applicant Email Address
Availability to start work
Availability over the next 12 months
Which part of the UK do you prefer to work in?
Declarations
In line with the Government legislation under the terms of the “Working Time Regulations” we recommend that your working hours should not exceed 48 hours per week (averaged over a 17 week period.)
Should you wish to waive this right, please confirm my ticking below:
I confirm that I wish to work more than 48 hours per week
I understand that the information provided on this form will be stored and processed by Ever Nurse in accordance with the Data Protection Act 1998 and the General Data Protection Regulation (GDPR) 2018. I consent to this information being made available for audit by relevant government organisations, such as CCS or the CPP Framework, where applicable.
In line with GDPR, I agree to the processing of my personal data for the purposes of recruitment, future employment opportunities, calculating remuneration, and maintaining records related to attendance, health, disciplinary matters, and grievances, as required for the fulfilment of my contract.
Further guidance can also be found via the Information Commissioner’s Office at
www.ico.org.uk
.
I confirm that I have received and read the terms and conditions of service issued by Ever Nurse, which I understand and agree to abide by. I also confirm that, to the best of my knowledge, I am fit for work and have no medical conditions or limitations that would affect my performance, other than those declared in my Pre-Employment Health Questionnaire.
I authorise Ever Nurse to disclose any criminal convictions to potential employers in line with the DBS Code of Practice and the Rehabilitation of Offenders Act. I declare that all information provided by me on this application form is accurate and complete. I understand that providing false or misleading information, or withholding relevant information, may result in my application being rejected, my employment being terminated, and the recovery of any payments received, including claims for loss of profit to Ever Nurse.
I also give Ever Nurse permission to apply for and check my DBS certificate annually via the UK DBS Update Service, as well as to conduct any necessary Right to Work checks through official government channels, if required.
Consent
I agree
I confirm that Ever Nurse has my permission to forward my CV and personal data (including, for example, occupational health details and DBS check information) for vacancies that match my stated preferences. I also give permission for Ever Nurse to carry out annual checks using the DBS Online Update Service.
Professional Registration Number
Are you currently undergoing an investigation by an NHS trust or your professional body?
Yes
No
If Psychiatry Doctor, do you have a Section 12 certificate?
Yes
No
Do you currently have medical insurance/professional insurance?
Yes
No
Qualifications
Configuration Required
Use the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.
Please complete in the table provided all professional qualifications held, including Post Graduate Diploma / Courses etc. Note that professional qualifications and training will be verified.
Child Protection / Venerable Adults level 2/3
Handling Complaints
Fire Procedures
Handling Violence & Aggression
COSHH & RIDDOR
Infection Control & Prevention
Lone Worker Training
Health & Safety
Risk Incident Reporting
Moving & Handling
The Caldicott Principles
Basic Life Support
Advanced Life Support
Have you been appraised within the last 12 months?
Yes
No
Full Name of Appraiser
In order to work within the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser”. Please give the details of the Senior Practitioner you have made arrangements with to act as your appraiser.
Position and Grade of Appraiser
Professional Registration Number of Appraiser
Appraisal Statement - Select if you agree with the following statements
I confirm the appraisal was within an "Approved NHS Appraisal System" and includes 360 degree feedback as well as feedback from patients.
I confirm that I maintain a written portfolio of my professional experience and attendance at proffessional development courses, which also includes a written and agreed "Personal Development Plan" as agreed at the appraisal.
Employment History
Can you please provide details in the boxes below of your last 3 years employment (most recent first). If there are any gaps of 3 month or more it is important that you explain the reason why in the box below.
Employer name (1)
Position Held (Employer 1)
Location (Employer 1)
Tel Number (Employer 1)
Date From (Employer 1)
Date To (Employer 1)
Employer name (2)
Position Held (Employer 2)
Location (Employer 2)
Tel Number (Employer 2)
Date From (Employer 2)
Date To (Employer 2)
Employer name (3)
Position Held (Employer 3)
Location (Employer 3)
Tel Number (Employer 3)
Date From (Employer 3)
Date To (Employer 3)
Professional Referees
You are required to supply at least two work related professional referees. The 2 referees provided must be within the last 12 months and be concurrent. If you have worked at the same Hospital for the last 12 months then we require 2 referees from that Hospital. Both referees must be a Consultant or Clinical Director. (We have allocated space for additional referees to be included, should you wish to provide more than two referees you must follow the above same principle.)
Name of First Referee
Email of First Referee
Address of First Referee
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Country
Phone of First Referee
Known Capacity of First Referee
Name of Second Referee
Email of Second Referee
Address of Second Referee
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Country
Phone of Second Referee
Known Capacity of Second Referee
Name of Character Reference
Email of Character Reference
Phone of Character Reference
Known Capacity of Character Reference
I give Ever Nurse Recruitment permission to forward my CV to agreed clients for the purpose of obtaining employment.
I Agree
Equal Opportunities Policy
As an Equal Opportunities employer, Ever Nurse welcomes applications from suitably qualified individuals across all areas of the community. We are committed to maintaining a working environment that promotes equality of opportunity and is free from discrimination based on race, nationality, religion, gender, social background, family responsibilities, marital status, sexual orientation, age, disability, or additional needs.
Our leadership team is dedicated to upholding best practices in equality, recognising the importance of fairness, legal compliance, and ethical responsibility. Equality is a core employment value, and we expect all staff and candidates to support and promote this principle.
To ensure the effectiveness of our policy, we carry out detailed monitoring, which involves collecting relevant information. The data provided will be treated with strict confidentiality, used solely for statistical purposes, and will not be seen by those involved in the selection process or affect your job application in any way.
Ethnicity
Criminal Record Declaration
Yes
No
If you have not completed a DBS check through Ever Nurse, or if your most recent check was carried out more than 12 months ago, you are required to complete the attached DBS form so we can process an Enhanced DBS check on your behalf. Please note that we cannot place you in an assignment without a valid and current DBS check in place.
To avoid delays, ensure that you include all original supporting documents (e.g. passport), as photocopies cannot be accepted. Any incomplete submissions or missing originals will result in your form being returned to you.
Disclosure Number
Date of Disclosure
Consent
I confirm that I have received, read and understood the contents of the Ever Nurse Locum Handbook and agree to comply with all policies and procedures outlined within it.
I also confirm that I have received, read and understood the terms and conditions of engagement issued by Ever Nurse.
I understand that my ID badge must be worn and visible at all times while on assignment through Ever Nurse, and that it must be returned upon the end of my engagement.
I consent to my personal data being shared with third parties where required, without the need for direct supervision from either myself or a member of Ever Nurse staff.
I Agree
Applicants Name
Interviewer's Name
Applicant/Candidate's Email
THE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.
Did the candidate have a good command of the English language?
Yes
No
Was the candidate pleasant and polite?
Yes
No
Was the candidate courteous and helpful?
Yes
No
Are you happy to offer this candidate work on the basis of this interview?
Yes
No
Thank you! Your submission has been received!
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