Application Form

Personal Details

* Required Fields

Title *

Surname *

Previous Surname *

Forenames (in full)

Date Of Birth *

Home Address*




Home Telephone Number *

Mobile Telephone Number

Other Telephone Number

Email Address *

Nationality *

Do you have the right to work in the UK? *

Work Permit Number (If Applicable)

National Insurance Number *


Do you hold a current UK driving licence? *

Do you have use of a car? *

Next of Kin






Telephone Number (Home)

Telephone Number (Work)

Are you registered with any other agencies?

How did you hear about Next Generation Staffing Group?




Next Generation Staffing Group is an equal opportunities employer, and these questions are asked solely for the purpose of ensuring that all applicants can be considered on an equal footing.



How many sick days have you had in the past 2 years?

Are you currently suffering from any illness or taking any prescribed medication?

If Yes, please give details

Have you been in recent contact with MRSA?

Have you ever suffered from back problems?

If Yes, please give details

Have you ever undergone any majos surgery?

If Yes, please give details

Date of last chest X-Ray

Vaccinations Received (with dates)







Hepatitis B

Have you travelled outside the UK?

Do you consider that you have a disability?

If Yes, please give details



Employment History (most recent first)

Full employment history back at least 10 years should be given, with any gaps fully explained.



Position Held

From (month/year)

To (month/year)

Reason For Leaving



Training Courses Attended / Qualifications Held


Name of Course

Date Attended

Qualification Gained



Experience Checklist

Bath/Shower/Strip Wash

Feeding a Helpless Patient

Use of Bath Aids

Ensuring Pressure Areas are Healthy

Mouth Care (including dentures)

Ensuring Medication has been taken

Care of Feet (including toenails)

Washing of Personal Laundry

Dressing/Undressing of Patients


Bed Bath

Changing a Bed/Drawsheet with patient in/on it


Sitting With a Terminal patient

Care of Hair

Dealt with Relatives of ill and terminally ill patients

Care of Fingernails

Observing Client Confidentiality

Care of Eyes

Report Writing/Giving

Care of Bladder and Bowels

Record Instructions from GP/District Nurse

Use of Bedpans/Commodes

Observe Changes in Patients/Clients condition and Report to person in charge of care

Emptying a Catheter Bag

Simple Dressing Procedure

Changing a Colostomy Bag

Light Housework

Recording Fluid Balance


Moving and Handling Patients

Experience in Hospice

Use of Walking Aids

Experience with Dementia

Use of Hoist

Experience in First Aid

Moving and Handling Course

Assisted with Last Offices

Blood pressure

Assisted with return of a patient from the operating theatre


Assisted with Care of a Patient after return from an Operating Theatre


Assisted with Occupational Therapy, including Recreation, Sports and Play

Weight Charts

Answered the Telephone, Taking, Recordingand Conveying Messages


Urine Testing

Obtain Simple Specimens

Preparation of Meals


Experience/Skill Obtained/Course Details

Date Achieved/Attended

Certificate Obtained?

Experience Only?

Enhanced Auxiliary Skills Course (Derriford)

Bereavement Counselling

Challenging Behaviour

Epilepsy Awareness

Administering Epilepsy Medication

Administering Insulin Injections

Medication Management

Control and Restraint

Learning Disabilities

Mental Health

NVQ in Care

Physical Intervention


Sign Language

Autism Awareness

Child Protection

Abuse of Elderly Awareness

Deputy Manager Experience



Other (please give details)

Preferred Contact Method?



Please use this space to add any comments in support of your application.



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