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Personal Details


Name of Establishment Date and Exam Taken Qualification Gained

Training Courses

Course Training Body Date Gained
Health and Safety
First Aid
Moving and Handling
Infection Control
Food Hygiene (HACCP)
Fire Training

Employment Record

Date From - To Name and Address Of Employer Position Held Reason for Leaving

If you are applying for a position as a registered nurse

How will you get to work if offered the post?

Reason for applying for this post and please state why you believe that you are suitable for this position:


  • Full Time
  • Days Only
  • Weekends Only
  • Part Time
  • Nights Only
  • Weekends Only
  • Either
  • Days or Nights
  • Flexible

When are you available to start work?

Criminal Records Check

Because of the nature of the work involved , the position you are applying for is exempt from the provisions of Section 4(2) of the Criminal Offenders Act 1974 (exceptions) Order 1975. You are therefore not entitled to withhold information about convictions which for other purposes as "spent" under the provisions of the Act. In the event that your services as an employee are retained by Amna Care Domiciliary, any failure to disclose such convicrtions, however long ago they occurred, could result in termination by the Company. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the Order applies.

Do you have any convictions to disclose?

Yes / No

If Yes, please provide full details about the date of the conviction(s) and the offence(s) involved

Eligibility to work in UK

Do you have permission to work in the UK?

Yes / No

Do you require a Work Permit?

Yes / No

Are you an Overseas Student?

Yes / No

In line with Home Office regulations on the prevention of illegal working, we will need a copy of your original ID Documentation to verify your right to work in the UK.


I confirm, to the best of my knowledge, I am clear from MRSA at present.

Should I come into any contact or have any suspicion that I have come into contact with MRSA, I will inform Amna care domiciliary ltd immediately.


Please provide the name and address of two people who will provide a reference for you. We would prefer one to be your current employer, but if this is not convenient for you, you may give the details of your previous employer. Relatives or colleagues cannot be used as a reference.

Data Protection

The information that you provide on this form and give at Interview will be used by Amna Care and domiciliary Ltd to provide you with suitable work opportunities. In completing this form, you agree to your information being added to our database and consent to us transferring your personal details to our Clients. We may also use or pass this information to certain third parties to detect crime, to protect public funds, or any other way permitted by law.

The information given on this application form is true, to the best of my knowledge, if not I understand that my contract with Amna Care and domiciliary Ltd will be terminated. I do consent to my information being added to the Amna Care and domiciliary Database. If during the course of temporary assignment I am offered a permanent position by the Client, Amna Care and domiciliary Ltd will be entitled to charge an introduction/transfer fee or to agree an extension of the employment for six months, after which I may be employed by the client without any further charge to either party.