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West Shore Medical Employment Application

The document is an employment application form for West Shore Medical Limited, requiring personal information, qualifications, employment history, and references. It includes sections for the applicant's contact details, marital status, job position applied for, and health-related questions. The form also contains a declaration regarding misrepresentation and consent for reference checks.

Uploaded by

Penelope Kalicharan
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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57 views2 pages

West Shore Medical Employment Application

The document is an employment application form for West Shore Medical Limited, requiring personal information, qualifications, employment history, and references. It includes sections for the applicant's contact details, marital status, job position applied for, and health-related questions. The form also contains a declaration regarding misrepresentation and consent for reference checks.

Uploaded by

Penelope Kalicharan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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WEST SHORE MEDICAL LIMITED


APPLICATION FOR EMPLOYMENT

SURNAME FIRST NAME

MIDDLE NAME MAIDEN NAME

ADDRESS

TELEPHONE NATIONALITY

EMAIL DATE OF BIRTH

MARITAL STATUS: PLEASE TICK


SINGLE MARRIED OTHER ___________________________
(PLEASE SPECIFY)

POSITION APPLIED FOR APPLICATION DATE

PRIMARY QUALIFICATIONS
DATE INSTITUTION QUALIFICATION

SECONDARY QUALIFICATIONS
DATE INSTITUTION QUALIFICATION GRADE

TERTIARY/ OTHER QUALIFICATIONS


DATE INSTITUTION QUALIFICATION GRADE

PLEASE SHOW CURRENT OR LAST EMPLOYER FIRST


COMPANY NAME: ADDRESS: TELEPHONE NO:

POSITION HELD: SUPERVISOR: SALARY/WAGE EARNED:

DATES EMPLOYED: REASON FOR LEAVING:

COMPANY NAME: ADDRESS: TELEPHONE NO:

POSITION HELD: SUPERVISOR: SALARY/WAGE EARNED:

DATES EMPLOYED: REASON FOR LEAVING:

COMPANY NAME: ADDRESS: TELEPHONE NO:

POSITION HELD: SUPERVISOR: SALARY/WAGE EARNED:

DATES EMPLOYED: REASON FOR LEAVING:

SALARY EXPECTED: ___________________________________________________

DATE AVAILABLE TO START WORK: ___________________________________________________

INTEREST/HOBBIES: ___________________________________________________
ARE YOU WILLING TO WORK:

SHIFTS WEEKENDS HOLIDAYS

TIME OF DAY:

DAYS EVENINGS NIGHTS

HAVE YOU EVER SUFFERED FROM ANY ILLNESS THAT MAY HAMPER YOUR PERFORMANCE,
INCLUDING BUT NOT LIMITED TO:

ASTHMA ALLERGIES EPILEPTIC FITS

HEART CONDITION DIABETES HIGH/LOW BLOOD PRESSURE

LUMBAR PAIN PAIN WHEN STANDING OTHER ________________________________________

HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE FOR WHICH A PARDON HAS NOT
BEEN GRANTED?

YES NO

ARE YOU RELATED TO ANYONE AT THIS FACILITY?

YES NO

3 REFERENCES NOT INCLUDING RELATIVES. AT LEAST ONE REFEREE MUST BE A


PLEASE LIST
FORMER EMPLOYER:
NAME: PHONE NO: OCCUPATION:

NAME: PHONE NO: OCCUPATION:

NAME: PHONE NO: OCCUPATION:

MAY WE CONTACT YOUR PRESENT EMPLOYER? YES NO

PLEASE READ CAREFULLY


I AGREE THAT ANY MISREPRESENTATION ON THIS APPLICATION FORM OR EMPLOYER DOCUMENTS COMPLETED AFTER HIRING MAY
BE CAUSE FOR REFUSAL TO EMPLOY ME OR REASON FOR DISMISSAL. I UNDERSTAND THAT ANY OFFER OF EMPLOYMENT IS
SUBJECT TO REFERENCE AND THAT ANY INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL.

APPLICANT’S SIGNATURE ______________________ DATE __________________

(N.B.: APPLICATION AND DOCUMENT COPIES ARE NON-RETURNABLE)

OFFICIAL USE ONLY

CERTIFICATE ORIGINAL SEEN RETURNED

CERTIFICATE COPIES SEEN KEPT

NURSING COUNCIL REGISTRATION (COPY) YES NO N/A

NURSING COUNCIL RENEWAL RECEIPT (COPY) YES NO N/A

PASSPORT DATA PAGE (COPY) YES NO N/A

PROOF OF VISA YES NO N/A

C.S.M.E. CERTIFICATE YES NO N/A

INTERVIEW _____________________________________________________ DATE _________________________

REMARKS ___________________________________________________________________________________

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