Dudley Nurse Registration

Important information to know before you begin

    Dudley

    General Information

    Please ensure you fill in all fields where possible, if a field doesn't apply please just use "N/A".






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    Current Address







    Address History if applicable

    If you've had a different address or addresses from your current in the last 5 years, please also include dates (month & year) moved in and out.

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    Personal Details










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    Professional Reference 1

    Your current or most recent employer




    Professional Reference 2

    Someone in a professional capacity i.e. nurse, doctor, manager etc




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    Payment Details

    This is an optional step. If you would prefer to give us this information over the phone or via email, please do not forget to do so.




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    ID Confirmation

    Please upload here three of the following Drivers Licence, Passport, Utility Bill or Birth Certificate (We need at least 3 of the 4 options)




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    Health Questionnaire

    All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

    Select N/A for not applicable.

    Select N/A for not applicable.

    Select N/A for not applicable.



    Next of Kin Details





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    Criminal Convictions




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    Training

    Please confirm you have in date practical training for the following:

    • Basic Life Support

    If you have completed training for any of the above, please specify the date completed e.g Basic Life Support - 01/12/2021

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    Employee Statement

    Choose the statement below that applies to you, either A, B or C.

    Statement A

    Do not choose this statement if you're in receipt of a State, Works or Private Pension.

    This is my first job since 6 April and Since the 6 April I've not received payments from any of the following:

    • Jobseeker's Allowance
    • Employment and Support Allowance
    • Incapacity Benefit

    Statement B

    Do not choose this statement if you're in receipt of a State, Works or Private Pension.

    Since 6 April I have had another job but I do not have a P45. And/or since the 6 April I have received payments from any of the following:

    • Jobseeker's Allowance
    • Employment and Support Allowance
    • Incapacity Benefit

    Statement C

    Choose this statement if:

    • You have another job and/or
    • You're in receipt of a State, Works or Private Pension

    Which of the statements above applies to you?

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    Student Loans

    Tell us if any of the following statements apply to you:

    • you do not have any Student or Postgraduate Loans.
    • you're still studying full-time on a course that your Student Loan relates to.
    • you completed or left your full-time course after the start of the current tax year, which started on 6 April.
    • you're already making regular direct debit repayments from your bank, as agreed with the Student Loans Company.

    Do any of these statements apply?

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    Student Loans Continued

    To avoid repaying more than you need to, choose the correct Student Loans that you have. Use the guidance below to help you.

    Plan 1

    • you lived in Northern Ireland when you started your course
    • you lived in England or Wales and started your course before 1 September 2012

    Plan 2

    • you lived in England or Wales and started your course on or after 1 September 2012

    Plan 3

    • you lived in Scotland and applied through the Student Award Agency Scotland (SAAS) when you started your course.

    Plan 4

    • you lived in England and Started your Postgraduate Master's course on or after 1 August 2016
    • you lived in Wales and started your Postgraduate Master's course on or after 1 August 2017
    • you lived in England or Wales and started your Postgraduate Doctoral course on or after 1 August 2018

    Choose all that apply:


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    COVID-19 Vaccination Record

    Please upload here your COVID-19 vaccination card as proof you're vaccinated against COVID-19.



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    GDPR Acceptances

    As part of the GDPR new law which came into effect in May 2018, Advantage Angels are conscious that all personal information given is processed in a fairly and lawful manner. Information is processed only for specified and lawful purposes.

    Please be advised that some information may be shared with only integral third parties. Personal data will be kept securely and not kept longer than necessary. Consequently, data will be destroyed suitably.

    Any questions, please contact our HR department, info@advantageangels.co.uk.

    Legal Acceptances

    I confirm that the information I have given on this form is correct and complete and I understand that any false information could result in my application being rejected or, if appointed, in my dismissal from employment. I understand that any offer of employment made to me will be subject to a further check with the Disclosure and Barring Service (previously Criminal Records Bureau) and I hereby give my consent for Coram to carry out the relevant DBS status checks in line with the DBS Code of Practice.

    I declare that I am not currently on the DBS Barred List and that I will notify the Human Resources department immediately if I do become barred in future.


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