image2.jpg

Providing temporary and short term contract Nursing staff and Healthcare Assistants to Public and Private Hospitals and Rest Homes in Wellington and throughout New Zealand.

    Registered and Enrolled Nurses Application Form

    Personal Details

    Surname:
    First Names:
    Address:
    Home phone:
    Cellphone:
    Email:
    Nationality:
    Are you a permanent resident/citizen of New Zealand?
     NO 
     YES 
    Do you have a work permit?
     YES 
     NO 
    If YES please provide evidence
    Date of New Zealand Nursing Registration  Select a date (yyyy-mm-dd)
    Entitled to practice as a:
    Do you hold a current New Zealand practising certificate? 
     YES 
     NO 
    Own transport?
     YES 
     NO 
    Licence type
    Licence number
    What geographical areas are you happy to travel to?
     Wellington 
     Porirua 
     Hutt Valley 
     Out of area assignments 

    Availability:

    Either : Select days any days and times that you are available. (Leave unchecked for days you are not avaliable)
    OR: Select yes will ring each week


    		MondayTuesdayWednesdayThursdayFridaySaturdaySunday
    AM
    PM
    6-11
    ND
    Clinical areas you are prepared to work in:
    Have you ever been employed at Capital & Coast District Health Board? 
     YES 
     NO 
    If YES, please state where and approximate dates as we need to get clearance for you to work there again:
    Are you currently applying for permanent work elsewhere?
     YES 
     NO 
    If YES, please elaborate:
    Are you listed with any other agency?
     YES 
     NO 

    Employment History

    Last employer
    Name:
    From:  Select a date (yyyy-mm-dd)
    To:  Select a date (yyyy-mm-dd)
    Duties:
    Second last employer
    Name:
    From:  Select a date (yyyy-mm-dd)
    To:  Select a date (yyyy-mm-dd)
    Duties:
    Have you been convicted for a criminal offence in the past 10 years (other than for minor traffic infringements) or have charges pending?
     YES 
     NO 
    If YES, please give full details

    Health Background

    Have you had a previous back/neck problem, work related injury or any medical or physical condition including mental illness that could affect your work? 
     YES 
     NO 
    If YES, please give full details.
    Are you currently taking prescribed medication?
     YES 
     NO 
    If YES, please give full details.
    Do you, or have you suffered from any infectious condition e.g. HIV, Hepatitis C, Tuberculosis etc? 
     YES 
     NO 
    If YES, please give full details

    Referees

    Referee 1
    Name:
    Position:
    Phone:
    Email:
    Referee 2
    Name:
    Position:
    Phone:
    Email:

    Declaration

    I declare that all the information I have supplied on this form is true and correct.  I further authorise any person or organisation to provide Duty Calls with such information as may be required in response to Duty Calls employment inquiries.