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Register with Nurses Link

To register with Nurses Link please fill out the following form. Please note that all fields are required. If you have any difficulty please contact us.

Personal

Title: 

First Name: 

Last Name: 

Address

Address: 

Postcode: 

State: 

Country: 

Contact Details

Telephone: 

Mobile: 

Fax: 

Email: 

Health Questions

There are some work situations where a disability may place at risk the health and safety of clients or people in their care.

For this reason we need to know whether you have any disability which might affect health and safety. We have identified some medical conditions, which might be relevant.

You are asked to identify any disabilities which are not mentioned.

Do you suffer from any of the following medical conditions (please tick):

Hepatitis A 

Hepatitis B 

Hepatitis C 

Epilepsy 

Back Complaints 

Manic Depression 

Schizophrenia

 

Any other medical conditions: 

Work History

Please list your employment history by name of employer, position held and length of service:

Qualifications

Do you hold or are you qualified in any of the following (please tick):

First Aid Certificate 

Enrolled Nurse 

To Carry Out CPR 

Registered Nurse 

Diploma in Nursing 

 

Any other qualifications held: 

Specialty Nursing

Please provide details of any specialty nursing you have done:

Extra Curricula Activities or Interests

Please list here:

Personal Statement

Make a personal statement about yourself and abilities:

References

Reference 1 Name: 

Phone Number: 

Address: 

Reference 2 Name: 

Phone Number: 

Address: 

Reference 3 Name: 

Phone Number: 

Address: 

Declaration

A. Have you ever been the subject of any official complaint that could have led to a conviction for an offence under the law (not including traffic offence complaints)?

Yes No

If yes, please provide details together with the outcome and any explanation you may wish to make:

B. Have you ever been dismissed from employment?

Yes No

If yes, please provide details together with any explanation you may wish to make:

C. Have you ever been the subject of a complaint of discrimination i.e sexual harassment or other forms of discriminatory conduct?

Yes No

If yes, please provide details together with any explanation you may wish to make:

D. Is there any information you may be aware of which you have not yet disclosed but which the employer might regard as being relevant to its decision to offer you employment?

Yes No

If yes, please provide details together with any explanation you may wish to make:

Declaration

I solemnly and sincerely declare that to the best of my knowledge and belief the information given in this application is true and correct.

Yes No ('dd/mm/yyy')

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