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Please select the most relevant area to your previous two years of clinical experience. (Hold CTRL key and click items from list to choose multiple items).

Personal Details

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Employment History

Education, Qualifications and employment details.

Please list details of all posts held since 2014. All breaks must be accounted for including time spent travelling or time taken out of work for any reason.

You will be required to provide a full 10 year work history later in the recruitment process.

  Activity Employer Hours Position From To Ward Name Ward Type/unit Reason


Please give details of your current or most recent line manager.

Please give details of your current or most recent line manager. You will be asked for additional references once your application has been vetted.

Reference details

Equal Opportunities

Equal opportunities

The aim of our policy is to ensure that no job application receives less favourable treatment on the grounds of race, colour, ethnic or national origin, religious belief, political opinion or affiliation, sex, marital status, sexual orientation, gender reassignment, age or disability, or is disadvantaged by conditions or requirements which cannot be shown to be justifiable.

Our selection criteria and procedures are frequently reviewed to ensure that individuals are selected, promoted and treated on the basis of their relevant merits and abilities.

All agency workers are given equal opportunity and are encouraged to progress within the organisation.

We are committed to an ongoing programmed of action to make this policy fully effective. To ensure that this policy is fully and fairly implemented and monitored, and for no other reason, would you please provide the following information:-

Age Group
Marital Status


Your record

The post applied for requires us to complete an enhanced disclosure including checks against the adult and children's barred lists.

Please note it is an offence to apply for this role if you have been barred from working with adults and or children.

Under the new filtering rules; certain offences may have been removed from your criminal records which you will not need to disclose.

If you are unsure whether your reprimand/ caution/conviction has been filtered, please refer to the Disclosure Barring Service (DBS) website for more information.

Please note, a criminal history will not necessarily be a bar to registration although failure to disclose any unspent convictions could lead to us withdrawing your application.


I declare that the information given by me on this application form to be accurate and correct. I can confirm that I am of sound physical and mental health and accept full responsibility for maintaining my general fitness to practice. I understand that the agency encourages me to benefit from professional indemnity insurance. I am entitled to take up paid employment in the U.K.

I hereby give permission for Thornbury Healthcare Professionals Recruitment Group to contact the Home Office/Border Immigration Agency in order to establish my current and ongoing immigration status and eligibility to work. I agree to complete an application at an enhanced level to the DBS. This will include a check against the children and adult barred list. I also agree to complete a pre-registration health declaration and full immunisation check in accordance with the Department of Health (DOH) and NHS Employer guidelines.

I understand that in this form I may have supplied information which constitutes sensitive personal data, as defined in the Data Protection Act 1998. I give my consent to the Agency to process such data for the purposes of health and safety and also as may be necessary for NHS audit and law and tax enforcement or assessment purposes. I consent to such information being passed on to such persons as shall be necessary for the purpose of assessing my suitability for an assignment.

Personal details of unsuccessful applicants may be retained for future jobs/correspondence.