www.jobs.nhs.

uk
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NHS STANDARD APPLICATION FORM For Office Use Only

Online Reference Number:
Please fill in the application form below. Do not type/write
using only capital letters and please remember to check it
carefully, as once the form has been submitted it cannot be
changed. If you wish to apply on-line you can do so at
www.jobs.nhs.uk. Please note that questions marked with an
asterisk * are mandatory and therefore must be answered.

APPLICATION FOR EMPLOYMENT WITH

NHS PROFESSIONALS

APPLICATION FOR EMPLOYMENT

Details entered in this part of the form will be held by the recruiting employer. Access to this
information will be withheld from the shortlisting panel. Please do not type/write using only
capital letters, as this could lead to your application being automatically rejected. Please use the
appropriate mixture of capital and lowercase letters in standard written text.

Job Reference Number

Job Title
Department

Personal Details

Title

*Surname/Family Name
Lomnasan
*First Name Daniela
Middle Name
Name in which you are registered
with a professional body (if
Nicolae Daniela
applicable)
UK National Insurance No ST 58 45 06 C / 17.05.2016

Address

*Postcode/ Zip code

*Country
Home Telephone
Mobile Telephone
(only if UK registered)
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NHS Jobs can send text messages to

UK registered mobile for key activities
associated with applications. 
Check this box if you wish to
receive updates by text message?
Work Telephone 0040 745 496657

Preferred telephone number  Home  X Mobile  Work

Email Address daniela.lomnasan@gmail.com

*Are you a United Kingdom (UK), European Community (EC) or European Economic Area
(EEA) National?
X Yes  No

If you have answered ‘no’ above, you must answer these questions:
Please select the category that relates to your current immigration status. This status will be
subject to checking before interview.

 Highly Skilled Migrant Programme/Tier 1  Post Graduate Doctors and Dentists

 Indefinite Leave to remain/enter  Tier 5 Temporary Workers
 Work Permit/Tier 2  Tier 5 Youth Mobility/ working holiday visa
 Dependant / Spouse visa  Refugee
 Clinical attachment visa
 Tier 4 student  Other, please specify below
 Visitor
-----------------------------------------------------------
Please supply details of any visa currently held:

Visa No:
Start Date: (DD/MM/YY)
Expiry Date: (DD/MM/YY)
Details of any Restriction:

Does your visa have a condition restricting employment or occupation in the UK?
 Yes  No
Are you an NHS professional returning to practice?  Yes  No

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APPLICATION FOR EMPLOYMENT

Details entered in this part of the form will be held by the recruiting employer and will be made
available to the short-listing panel.
Online reference
Job Reference Number
number
Job Title
Department

Education & Professional Qualifications

All relevant qualifications. Please also indicate subjects currently being studied. All
qualifications disclosed will be subject to a satisfactory check.
Year
Subject/Qualification Place of Study Grade/result
obtained
General Nurse School of 9,07 2016
Nursing”Dr.Balin
Alexandru”Medias

Training Courses Attended

Training courses that you have attended or details of courses that you are currently
undertaking, together with the date completed or to be completed.
Year
Course Title Training Provider Duration
obtained
School of Nursing Fundatia “Dr.Balin 2013-2016 2016
Alexandru” Medias

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Membership of Professional Bodies

Please provide details regarding any relevant professional registrations or memberships. This
information will be subject to a satisfactory check.

* Please indicate your UK Professional Registration status *

 I do not have the relevant UK professional registration status

 I have current UK professional registration

 UK professional registration required and applied for

X UK professional registration required but not yet applied for

 I am a student

 Not required for this post

If professional registration is not required then go to Employment History.

If you have answered ‘I have current UK professional registration relevant for this post’ or ‘I
have current UK professional registration and licence to practise for this post’, then please
enter the relevant details below.
Membership or Membership/Registratio Expiry/Renew
Professional Body
Registration type n Number al Date

If you are applying for a post that requires professional registration you are required to provide
the following information:
Are you currently the subject of a fitness to practise investigation or
 Yes
proceedings by a licensing or regulatory body in the UK or in any other
X No
country?
If applicable, please provide details of any investigations or proceedings you may be subject
to.

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Have you been removed from the register or have conditions been made
on your registration by a fitness to practise committee or the licensing or Yes
regulatory body in the UK or in any other country? X No
If applicable, please provide details of any conditions you may have.

Employment History
Please record below the details of your full employment history beginning with your current or
most recent first. If required, please provide additional information regarding your employment
history within the 'Supporting Information' section.

Start of continuous NHS service (If applicable) (MM/YYYY)

Months since most recent employment ended (if applicable)

Current/most recent employer

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job title) Period of notice
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

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Previous Employer 1

Employer Name
SMURD Copsa-Mica, jud.Sibiu

Copsa-Mica, Str.Aleea Castanilor, nr.8, jud.Sibiu

Address

Type of Business Telephone 0040 729 636363

Job Title Volunteer
Start Date (MM/YYYY) November 2013 End Date (MM/YYYY) July 2014
Grade Salary
Reporting to (job title) Period of notice
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

-Work as part of a medical team
- Respond to emergency situation
-Managing the risks from accidents
-Managing difficult situations and remain calm under pressure
-Monitoring vital signs( temperature, pulse, respiration, blood pressure)
-Practising ALS, BLS, RCP

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Previous Employer 2

Employer Name Serviciul Judetean de Ambulanta Sibiu-Statia Medias

Address
Medias, Str.I.G.Duca, nr.33, jud.Sibiu

Type of Business Telephone 0040 269 842550

Job Title Volunteer
Start Date (MM/YYYY) November 2014 End Date (MM/YYYY) March 2015
Grade Salary
Reporting to (job title) Period of notice
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

-The same responsabilities and duties from SMURD

Previous Employer 3

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job title) Period of notice

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Reason for leaving (if applicable)

Brief description of your duties and responsibilities

Previous Employer 4

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job title) Period of notice
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

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Previous Employer 5

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job title) Period of notice
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

Previous Employer 6

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job title) Period of notice

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Reason for leaving (if applicable)

Brief description of your duties and responsibilities

Please add additional employers/information on a separate sheet.

Employment Gaps

If you have any gaps within your employment history, please state the reasons for the gaps
below.

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References
Please provide the names and full contact details of the people who have agreed to supply
references. References must include at least two positions with separate employers and, as a
minimum, cover a period of three years employment and/or training history, where this is
possible.

Referees will be required to comment on your competence, personal qualities and suitability for
the post. This may be your line/department manager, or someone in a position of responsibility
for any work experience or placement undertaken. If you are a student or trainee this should
include a teacher/tutor at your education institution.

If you have not been in employment for a considerable amount of time but have had previous
employment, then you should seek one reference from your last known employer and a
personal reference from a person of standing within your community such as a doctor, solicitor
or MP. Where it is genuinely not possible to obtain references from any of the sources outlined
above, you must provide contact details of two personal acquaintances who would be willing to
give a reference. Personal acquaintances must not be related to you, or have any financial
arrangement with you.

Please note that all reference requests will be followed up and verified by the recruiting
employer.

Referees may be approached prior to interview, unless you indicate otherwise below.

Referee 1
* Type of Reference  Employer  XEducational  Personal
Title
*Surname/Family name Dr.Balin * First Name Alexandru
*Relationship Doctor and director from the Nursing School where i graduated
Employer Name
Referee Job Title
*Address Medias, Str. Sibiului, nr.60

*Postcode/ Zip Code 551129

Telephone 0040 269 831670 *Country Romania

Email Fax
*Can the referee be
contacted prior to X Yes  No
interview?

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Referee 2
* Type of Reference  Employer X Educational  Personal
Title
*Surname/Family name As.Blajan * First Name Daniela
*Relationship Nurse and my tutor
Employer name
Referee Job Title
*Address Medias,str.Sibiului, nr.60

*Post Code/ Zip Code 551129

Telephone 0040 726 705602 *Country Romania

Email Fax
*Can the referee be
contacted prior to  XYes  No
interview?

If you have applied to us within the last 3 months,

are you happy for us to use the references from  Yes  No
your earlier application?

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Supporting Information
In this section please give your reasons for applying for this post and additional information
which demonstrates that you have read the published person specification and how you meet
the essential and (where relevant) desirable criteria for this particular position. This can include
relevant skills, knowledge, experience, voluntary activities, training etc.

If relevant to the post for which you are applying, you should include details about research
experience, publications or poster presentations, clinical care (knowledge and skills) and clinical
audit.

* Supporting information (Please continue on additional sheets if necessary).

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Additional Personal Information

Preferred Employment X Full Time  Part Time  Job Share Secondment

Type  Flexible Hours

Declaration

The information in this form is true and complete. I agree that any deliberate omission,
falsification or misrepresentation in the application form will be grounds for rejecting this
application or subsequent dismissal if employed by the organisation. Where applicable, I
consent that the organisation can seek clarification regarding professional registration details.

I agree to the above declaration

Signature

Name Daniela Lomnasan Date 21.09.2016

Where did you see this vacancy advertised?

 NHS Website  Local Newspaper  Doctor  Nursing Standard
 Search Engine  British Medical  Therapy Weekly  Other Professional
 Other Website Journal  Nursing Times Journal
 National  British Dental Journal  GP  Jobcentre Plus
Newspaper  Health Service  Hospital Doctor  Radio
Journal  XOther

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MONITORING INFORMATION
NHS organisations recognise the benefits of having a diverse workforce and therefore welcome
applications from all sections of the community. In addition to this, under the provisions of the
Equality Act 2010, all NHS organisations are required to demonstrate that their recruitment
processes are fair and that they are not discriminating against or disadvantaging anyone
because of their age, disability, gender reassignment status, marriage or civil partnership status,
pregnancy or maternity, race, religion or belief, sex or sexual orientation. Therefore a series of
questions need to be raised in order to ascertain who is applying for each position and to
ensure that no one is being unfairly discriminated against or disadvantaged.

This section of the application form will be detached from your application and will not be used
as part of the selection process nor will it be seen by anybody who is interviewing you. The
information collected is only used for monitoring purposes in an anonymised format to assist the
organisation in analysing the profile and make up of individuals who apply, are shortlisted for
and appointed to each vacancy. In this way, they can check that they are complying with the
Equality Act 2010.

Equality Act 2010

The Equality Act 2010 protects people against discrimination on the grounds of their age and
sex.

* Please state your date of birth

 Male
* Please indicate your gender  X Female
 I do not wish to disclose this

Equality Act 2010

The Equality Act 2010 protects people who are married or in a civil partnership.
* Please indicate the option which best describes your marital status
 Married
X Divorced
 Single
 Widowed
 Civil partnership
 I do not wish to disclose this
 Legally separated

Equality Act 2010

The Equality Act 2010 protects bisexual, gay, heterosexual and lesbian people from
discrimination on the grounds of their sexual orientation.
* Please indicate the option which best describes your sexual orientation

 Lesbian
X Heterosexual
 Gay
 I do not wish to disclose this
 Bisexual

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Equality Act 2010

The Equality Act 2010 protects people against discrimination on the grounds of their race which
includes colour, nationality, ethnic or national origin.

* Please indicate your ethnic origin

Asian or Asian British Mixed Other Ethnic Group

 Bangladeshi  White & Asian  Chinese
 Indian  White & Black African  Any other ethnic
 Pakistani  White & Black Caribbean group
 Any other Asian  Any other mixed
background background
 I do not wish to
Black or Black British White disclose this
 African  British
 Caribbean  Irish
 Any other Black X Any other White
background background

Equality Act 2010

The Equality Act 2010 protects people against discrimination on the grounds of their religion or
belief, including a lack of any belief.
* Please indicate your religion or belief
 Atheism  Islam  Other
 Buddhism  Jainism  I do not wish to disclose this
 XChristianity  Judaism
 Hinduism  Sikhism

Equality Act 2010

The Equality Act 2010 protects disabled people - including those with long term health
conditions, learning disabilities and so called "hidden" disabilities such as dyslexia. If you tell us
that you have a disability we can make reasonable adjustments to ensure that any selection
processes - including the interview - are fair and equitable.

* Do you consider yourself to  Yes XNo

have a disability?  I do not wish to disclose this information
Please state the type of impairment which applies to you. People may experience more than
one type of impairment, in which case you may indicate more than one. If none of the
categories apply, please mark ‘other’.
 Physical impairment  Learning Disability/Difficulty
 Sensory impairment  Long-standing illness
 Mental health condition  Other
If you have a disability, do you wish to be considered under the guaranteed interview scheme
if you meet the minimum criteria as specified in the person specification?

 Yes  No

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Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act 1974 (as amended) helps rehabilitated ex-offenders back
into work by allowing them not to declare criminal convictions after the rehabilitation period set
by the Court has elapsed and the convictions become 'spent'. During the rehabilitation period,
convictions are referred to as 'unspent' convictions and must be declared to employers.

The organisation aims to promote equality of opportunity and is committed to treating all
applicants for positions fairly and on merit regardless of ethnicity, disability, age, gender or
gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and
marriage or civil partnership. The organisation undertakes not to discriminate unfairly against
applicants on the basis of a criminal conviction or other information declared.

You are required to declare all current ‘unspent’ criminal convictions or cautions (including
reprimands and final warnings). You are not required to disclose convictions or cautions which
have become ‘spent’.

As part of assessing your application, organisations will only take into account relevant criminal
record and other information declared which is relevant to the position being applied for.

Answering ‘yes’ to the question below will not necessarily bar you from appointment. This will
depend on the relevance of the information you provide in respect of the nature of the position
for which you are applying and the particular circumstances.

* Are you currently bound over or do you have any current ‘unspent’ convictions or cautions
(including reprimands or warnings) that have been issued by a Court or Court-Martial in the
United Kingdom or in any other country?
 Yes X No
If Yes, please include details of the order binding you over and/or the nature of the offence,
the penalty, sentence or order of the Court, and the date and place of the Court hearing. You
do not need to tell us about parking offences.

Relationships
If you are related to a director, or have a relationship with a director or employee of an
appointing organisation, please state the relationship:

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