Admin Form No 62
JOHN MUNROE HOSPITAL GROUP
Horton Road
Rudyard
Nr Leek
Staffs
ST13 8RU
Tel: 01538 306244
Edith Shaw Hospital
5 Hugo Street
Leek
Staffs
ST13 5PE
Tel: 01538 384082
Reviewed 11
th
November 2010
Review 11
th
November 2013
Issue 7
PH/MR
Application for Employment
PRIVATE AND CONFIDENTIAL Please complete in BLOCK CAPITALS
Position applied for: REGISTERED NURSE
How did you hear of this vacancy? (include date) IMS RECRUITMENT (OCTOMBER)
A. PERSONAL PARTICULARS
Title:
Mr Mrs
X
Miss Ms Other
Surname:
URSU
Forename(s)
NINA
Marital Status:
MERRIED
Maiden Name
NEAGU
Address:
BACAU, STR. DIGUL BARNAT 17/A/8
Telephone Number (including STD Code)
0040758407775
Home:
Mobile:
0040758407775
Work:
e-mail address:
nina_noor@live.it
(Tick box if you do not want to be
contacted at work).
N.I. Number:
SP807525B
ISA Registration Number: Do you need a work permit to take up
employment in the U.K.?
Yes/No
?
Are you over 18 years
of age
Yes
X
No Detail:
ROMANIA
B. EDUCATION AND QUALIFICATIONS
QUALIFICATIONS: Please give details of examinations attempted and results (including any examinations failed)
Name(s) and Address(es)
of School(s)/College(s)
Dates Subject/Courses
Studied & Level
Examination Result/
Grade (include any
examinations failed)
From To
FEG POSTGRADUATE
SCHOOL BACAU
2009 2012 REGISTERED NURSE 9.85
UNIVERSITY OF
PSYCHOLOGY PETRE
ANDREI IASI
2009 2012 PSYCHOLOGYST 8.35
ENGLISH COURSE
2012
10.00
ACCOUNTING COURSE
1992
10.00
Admin Form No 62
JOHN MUNROE HOSPITAL GROUP
Horton Road
Rudyard
Nr Leek
Staffs
ST13 8RU
Tel: 01538 306244
Edith Shaw Hospital
5 Hugo Street
Leek
Staffs
ST13 5PE
Tel: 01538 384082
Reviewed 11
th
November 2010
Review 11
th
November 2013
Issue 7
PH/MR
FURTHER AND HIGHER EDUCATION: Please give details of all further and higher education since leaving
school including training courses and details of qualifications.
NVQs in Care 2 3 4
Please state date acquired
University/College/
Institute Attended
Dates Subjects Studied
Type of Training
Qualifications
Obtained From To
Please give details of any experience, skill or achievements which you feel may be relevant in your application for
employment. (Continue on separate sheet if necessary).
physical and psychological support to patients,
patient education and compliance conditions on hygienic-dietary regime,
special needs patient care before and after surgery, medical procedures, in recovery, etc..
gastro stoma (PEG) - care and alimentation, tracheal stoma (suction, aspiration, care ), nebulizer, embrocation
checking and administering medication orally, intravenously, intramuscularly, subcutaneously, intradermally according to the prescription
measurement and notation in clinical chart the patient's vital signs ( blood pressure, pulse, temperature, diuresis, BO, skin color, etc..)
gastrointestinal tract wash, eye wash, wash bladder, genital washes,
gastro duodenal catheter, urinary catheter,
sterilizing instruments
patient preparation, materials and assisting the doctor in pleural punction, pericardial punction, abdominal punction, etc..
collected blood, urine, secretions, exudates, vomiting and other pathological materials for laboratory examination
first aid in emergencies and care of open wounds, burns, fractures, sprains,
prepare the patient for the necessary investigations
washing and dressing patientss
giving medication
managing 6 care - rehab assistants
respected the professional secrecy;
inform and participate in training courses
FOREIGN LANGUAGES: Please list any foreign languages you speak and your level of competence, both oral
and written:
ITALIAN ADVANCED
ENGLISH INTERMEDIATE
FRANCE - BEGINNER
Admin Form No 62
JOHN MUNROE HOSPITAL GROUP
Horton Road
Rudyard
Nr Leek
Staffs
ST13 8RU
Tel: 01538 306244
Edith Shaw Hospital
5 Hugo Street
Leek
Staffs
ST13 5PE
Tel: 01538 384082
Reviewed 11
th
November 2010
Review 11
th
November 2013
Issue 7
PH/MR
C. EMPLOYMENT HISTORY
Please list starting with the most recent, all the organisations for which you have worked during the last 20 years:
Name(s) and Address(es)
of Employer(s)
Dates Position Held/
Main Duties
Starting/
Leaving Salary
Reason for
Leaving From To
RAPHAEL MEDICAL
CENTRE
15.05.2013
01.10.2013
NURSE
1600-1800
PERSONAL
COUNTRY HOSPITAL
BACAU
01.11.2009
15.04.2013
NURSE
VOLUNTEERING
HOTEL LE CONCHIGLIE
RICCIONE ITALY
15.03.2000
30.09.2009
RECEPTION
HOTEL
1600-200
SEASONAL
TENERIFE IMPORT
EXPORT SRL
15.01.1992
15.02.2000
ACCOUNTANT
400-700
FINANCIAR
UNEMPLOYED
Please list any periods of unemployment
Reason for unemployment Dates
From To
Admin Form No 62
JOHN MUNROE HOSPITAL GROUP
Horton Road
Rudyard
Nr Leek
Staffs
ST13 8RU
Tel: 01538 306244
Edith Shaw Hospital
5 Hugo Street
Leek
Staffs
ST13 5PE
Tel: 01538 384082
Reviewed 11
th
November 2010
Review 11
th
November 2013
Issue 7
PH/MR
D. SUPPLEMENTARY INFORMATION
Salary Range Expected:
How much notice are you required to give to leave your present employment?
Weeks
Please give dates of any holidays arranged:
From: To:
From: To:
From: To:
Have you worked for us before?
If Yes, give further details:
Position:
Dates:
No
Are you related to any employee within the organisation?
If Yes, please give further information:
No
Do you have a current full driving licence?
Yes
Does your licence have any current endorsements?
If Yes, please give further information:
No
PROFESSIONAL ASSOCIATIONS: Please state whether you are a member of any technical or professional
association, and if so, which:
Registration Number:
NMC PIN NUMBER 12L0226C
Date of first registration: Date registration expires:
28.12.2012
Registration Number:
OAMMMR BACAU ROMANIA BC 004426
Date of first registration: Date registration expires:
07.09.2012
Admin Form No 62
JOHN MUNROE HOSPITAL GROUP
Horton Road
Rudyard
Nr Leek
Staffs
ST13 8RU
Tel: 01538 306244
Edith Shaw Hospital
5 Hugo Street
Leek
Staffs
ST13 5PE
Tel: 01538 384082
Reviewed 11
th
November 2010
Review 11
th
November 2013
Issue 7
PH/MR
Rehabilitation of Offenders legislation: Because of the nature of work for which you are applying, this post is
exempt from the provisions of the above legislation. Offer of employment will be subject to receipt of a
satisfactory Disclosure from the Criminal Records Bureau/Office which will be reviewed every 3 years.
Information received will be treated in the strictest confidence and will generally be retained by the Organisation
for a period of at least 6 months or as deemed necessary. A criminal record will not necessarily be a bar to
obtaining employment with the Organisation.
Have you any criminal convictions?
If yes, give further details:
No
Have you been the subject of any investigation or enquiry into abuse or inappropriate
behaviour.
If yes, give further details:
No
Are you currently the subject of a fitness to practice investigation or proceedings by a
licensing or regulatory body in the UK or in any other country?
If yes, give further details:
No
Are you currently subject to any contractual "restraints of trade" clauses?
If yes, give further details:
No
Admin Form No 62
JOHN MUNROE HOSPITAL GROUP
Horton Road
Rudyard
Nr Leek
Staffs
ST13 8RU
Tel: 01538 306244
Edith Shaw Hospital
5 Hugo Street
Leek
Staffs
ST13 5PE
Tel: 01538 384082
Reviewed 11
th
November 2010
Review 11
th
November 2013
Issue 7
PH/MR
E. REFERENCES
Please give the names and addresses of your two most recent employers, who we can approach for a
confidential assessment of your suitability for this job.
If you have not been employed the names and addresses of two referees who we can approach to obtain
character references.
(Tick in box if you do not wish your employer to be contacted before an offer of employment is made)
Name:
RAPHAEL MEDICAL CENTRE
Name:
PEPINA MARILENA
Address:
Address: COUNTRY HOSPITAL BACAU
HILDENBOROUGH, TONBRIDGE, KENT
TN11 9LE
Telephone Number: 01732833923
Telephone Number: 0040742575185
Position:
Position: HEAD REGISTERED NURSE
DECLARATION OF APPLICANT
I confirm that the information I have provided on this application is correct.
I understand that any false information or deliberate omissions will disqualify me from employment or may render
me liable for dismissal.
I consent to the Organisation using and keeping information I have provided on this application or elsewhere in
the recruitment process and/or personal information supplied by third parties, such as referees, relating to my
application or future employment. I understand that the information provided will be used to make a decision
regarding my suitability for employment and, if successful, the information will be used to form my personnel
record and will be retained for the duration of my employment. If I am not successful, I understand that the
Organisation will normally retain the application for a period of at least 6 months, and may use it to contact me in
the event of there being any other vacancies for which I may be suitable.
Signed: URSU NINA
Date: 31.10.2013
Admin Form No 62
JOHN MUNROE HOSPITAL GROUP
Horton Road
Rudyard
Nr Leek
Staffs
ST13 8RU
Tel: 01538 306244
Edith Shaw Hospital
5 Hugo Street
Leek
Staffs
ST13 5PE
Tel: 01538 384082
Reviewed 11
th
November 2010
Review 11
th
November 2013
Issue 7
PH/MR
EQUAL OPPORTUNITY MONITORING
John Munroe Hospital is committed to a policy of Equal Opportunity. In order to monitor the
effectiveness of this policy, all applicants for employment are asked to complete this form. This
information will not be used in the selection process and will only be disclosed to staff in the Personnel
Office who process the data. All information will be held in confidence.
VACANCY: REGISTERED NURSE
MALE / FEMALE: FEMALE
AGE 41
DISABILITY
In order to ensure that people with disabilities can compete fairly for jobs at John Munroe Hospital, it
would be helpful if you could answer the following questions:
Are you disabled? No
If yes, please state the nature of your disability:
Would the Hospital need to make any special provisions to enable you to attend for interview? If so,
please give details:
NO
ETHNIC ORIGIN
Which one of the following groups do you feel most adequately describes your ethnic origin?
Choose one from the appropriate sections:
Section 1
White X Black Asian Mixed
Section 2
English Scottish Welsh Irish Other ROMANIA
Section 3
White and Black
Caribbean
White and Black
African
White and Asian
Any other Mixed background
_______________________
Section 4
Admin Form No 62
JOHN MUNROE HOSPITAL GROUP
Horton Road
Rudyard
Nr Leek
Staffs
ST13 8RU
Tel: 01538 306244
Edith Shaw Hospital
5 Hugo Street
Leek
Staffs
ST13 5PE
Tel: 01538 384082
Reviewed 11
th
November 2010
Review 11
th
November 2013
Issue 7
PH/MR
Indian Pakistani Bangladeshi Caribbean African
Chinese Other ___________
I understand that the information given on this form will be used in accordance with provisions of Data
Protection Act (1998).
For the successful candidate the information will form part of their confidential personnel record.
Further details of how the data will be processed will be supplied with the offer of employment. In the
case of unsuccessful candidates, the data will only be used for statistical purposes and will kept for up
to two years.
Signature: URSU NINA Date: 31.10.2013
PLEASE DETACH THIS FORM PRIOR TO INTERVIEW
