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Application for Employment Form Please complete this form in full supplemented by additional sheets if necessary. CV’s WILL NOT BE ACCEPTED All personal data supplied to us on this form, which is subsequently processed on computer or by other means, is subject to the provisions of the Data Protection Act 1998. Position applied for:

Job Reference No:

Location:

Care/Support worker

CWC/ CSWPT

Cardiff

Professional Journal

Where did you see this job advertised? Newspaper

ys ss s

Job Centre

Care UK website

Friend

Other

………………………….

Personal details Surname:

Title: (Mr/Mrs/Miss/Ms/Dr/Prof)

First names: (for official purposes)

MADIBA

MRS

Grace, Moso, nkatle

Current Address: 72 Tudor street . Riverside Cardiff

Previous Surname:

Kgamanyane, Segosebe Preferred Name: (name you wish to be known as) County

UK

Date moved into this address: DD 09

Post Code: CFII 6AL MM 10

YYYY2011

E-mail address:

Grace Home telephone number: Mobile telephone number:

grace__segoebe@yahoo.com

07572076086

Due to certain legal requirements some of our roles have a minimum age restriction Are you under 18 years of age? Are you between 18 and 21 years of age? Are you over 21 years of age?

* / NO * / NO *YES /

*Delete as appropriate *Delete as appropriate *Delete as appropriate

Do you hold a current valid driving licence? I HOLD A BOTSWANA DRIVING LICENCES CLASS B, Do you require permission to work in the UK?

*YES /

* Delete as appropriate

Employment (if applicable) Name of current/last employer: STUDENT- CARDIFF UNIVERSITY Start Date: 10/10/2011

End Date:13/10/2011

Title/description of your current job and key responsibilities:

Current /Final Salary: What period of notice are you required to give to your present employer? Reason for wishing to leave:

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Application for Employment Form Previous Employment Please list your full employment history and explain any breaks in employment and how this time was spent. (Continue on a separate sheet if necessary) Start Date

End Date

Job Title

Name of Employer

Reason for Leaving

1992

ENROLLED NURSE

TRANSFER

1998

ENROLLED NURSE

MINISTRY OF HEALTH, NORTHWEST DISTRICT COUNCIL GABORONE CITYCOUNCIL CLINI CS

2001

REGISTERED NURSE

TRANSFER

2008

REGISTERED NURSE/MIDWIFE

GABORONE CITYCONCIL AND KWENENG DISTRICT COUNCIL NORTHWEST DISTRICT COUNCIL

March 2011

REGISTERED NURSE/MIDWIFE

GHANZI DISTRICT COUNCIL CLINICS

ON STUDY LEAVE AND RESIGNED

11/10/1987

1993

1999

2001

2008

TRANSFER

TRANSFER

Hobbies and Interests READING AND TRAVELLING

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Application for Employment Form Education and Qualifications Date Gained

Subject ENROLLED NURSING

Qualification and Grade PASSED

Awarding Institution DEBORAH RETIEF MEMORIAL SCHOOL OF NURSING

DIPLOMA IN REGISTERED NURSING

CREDIT

SEROWE INSTITUTE OF HEALTH SCIENCES.

DIPLOMA IN MIDWIFERY

MERIT

FRANCISTOWN INSTITUTE OF HEALTH SCIENCES BOTSWANA

SEPTEMBER 1987

SEPTEMBER 2000 September 2006

Training Date

Topic Covered

Training Provider

1989

Dental nurse,prevention,control and treatment Hiv counseling and testing Adolescent sexual and reproductive health Prevention of mother to child transmission of Hiv infection Sexual transmitted infection ,prevention and treatment Management of homebased care patients.egchronically ill,elderly,disabled patients Introduction to computer skills Infection control,safety and Health

Maun dental hospital

2oo1 2002 2003

2004

2004

2005 2005

Ministry of health, Botswana Ministry of health, Botswana Ministry of health

Ministry of health

Ministry of health

Ministry of health Ministry of health

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Application for Employment Form Issuing Body

Botswana Nursing concil

Registration Number

RN 578 MD 3048

Date Gained

Expiry Date

SEPTEMBER 2000 SEPTEMBER 2006

DECEMBER 2012

For Teaching Positions DFES Number:

Member of General Teaching Council:

* / NO

*Delete as appropriate

Suitability Please assess yourself against the requirement of the Person Specification, giving examples of how you meet the defined criteria (see Guidance for Applicants document). Ensure you are concise and to the point. You may continue on to one additional sheet if necessary.

Firstly, I have more than 10 years working as a nurse/ midwife and basically my duties and responsibilities are to provide nursing care services to patients either inpatients or outpatients. For example, washing , bathing,showering,oralcare, grooming ,toilet assisting with use of bedpan and emptying it, undressing and dressing wounds, assisting to feed and drink and administering medication. Furthermore, one of my main duties includes provision of home based care nursing services to patients in their home, for instance,chronically ill patients, elderly and patients with disabilities. Services provided here are :bathing , oralcare, changing linen, dressing, administering medications and assisting patient to eat and drink. In addition, assist in cleaning of patients surroundings, bedmaking, laundry and shopping. Moreover, I assisted patients for medical checkups and refer to doctor or health center when necessary. Finally, other duties and responsibilities included working as a manager, for example ,incharge of a health facility therefore supervising staff, documentation of reports and patients statistics ,compiling them and sending to senior offices. Ordering of drugs and cleaning equipments and disfectants. Ensuring smooth running of the health clinic by monitoring daily staff presence and establishing good working relationships and advocate for a good nurse patient relationship and user friendly services..

Referees Please give the names and addresses of 2 referees that cover the last 3 years of your employment, one of these must be your current or most recent employer and both must be your line managers. The third reference can be a character reference from someone who has known you for over 3 years. NB: WE CANNOT ACCEPT ANY REFERENCES FROM FAMILY MEMBERS. Can we contact these references prior to interview:

* YES / NO *Delete as appropriate

Name and Address 1.MS O DISSIPI

Telephone Number 002676596211

2.MRS K . MORAPEDI

002676860241

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Fax Number

Email Address

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Application for Employment Form

2.

This is my previous Line Manager *Yes /

3.

*Delete as appropriate

Additional Information Please give below any further information that is relevant to your application, eg: your application is for a job share; periods of time when you would be unavailable for interview; any special requirements should you be invited for interview. MY APPLICATION IS FOR A PART TIME JOB. WORKING ON EVENINGS, WEEKENDS, HOLIDAYS, NIGHTDUTIES AND FLEXIBLE DURING THE SCHOOL HOLIDAYS.

DECLARATIONS Rehabilitation of Offenders Act 1974 The nature of the work for which you are applying involves working with vulnerable adults or children. Therefore, the post is exempt from the provisions of Section 4 (2) of the above Act and all applicants who are offered employment will be subject to a criminal record check from the Criminal Records Bureau before the appointment is confirmed. Applicants are NOT entitled to withhold information about convictions which are considered SPENT under the provision of the Act. Having a criminal record will not necessarily prevent you from working with us; this will depend on the nature of the position and circumstances and background of your offence. Have you at any time been convicted of an offence, spent or unspent? Have you ever received any cautions, reprimands, final warnings or convictions?

* / NO * / NO

*Delete as appropriate *Delete as appropriate

Independent Safeguarding Authority You are also required to declare if your name is included on the register maintained by the Independent Safeguarding Authority (previously, The Protection of Children Act List, The DfES List 99 and the Protection of Vulnerable Adults List). Has your name been added to the Independent Safeguarding Authority Register?

* / NO

*Delete as appropriate

Professional Conduct Have you been subject to any investigation into your professional conduct by any licensing, regulatory or professional body in the UK or any other country where the outcome was adverse? * / NO *Delete as appropriate Have you been removed, contingently removed or suspended from, refused admission to, or conditionally included in any list or equivalent list kept by a PCT, NHS Trust or equivalent professional or regulatory body, or are you currently suspended from such a list in the UK or any other country? *Y / NO *Delete as appropriate RECF002 external app form

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Application for Employment Form Are you currently the subject of any investigation by any professional organisation in the UK or any other country, which might lead to your removal from any of their lists? * / NO *Delete as appropriate At the same time I agree to inform Care UK immediately if any such investigation should be initiated. This includes issues, which may lead to such an investigation and/or have any bearing on my suitability to this post? * / NO *Delete as appropriate If you have answered YES to any of the above questions please give details on a separate sheet. Any information supplied will remain confidential and will be considered only in relation to your application for this post. Please read and sign: I confirm that the information given on this form is, to the best of my knowledge and belief, true and complete. I understand that Care UK is not legally allowed to employ persons who are deemed “not fit” to work with vulnerable adults or children and that if any of the information I have given is found to be false or misleading, Care UK can withdraw their offer of employment to me, or cancel their agreement with me. I understand that if this is discovered at a later date, I may be dismissed. I also give my consent to the processing of my personal data by computer or other means in relation to my job application and possible future employment.

Signed GMN

MADIBA………………………………………………………..................... Date 15/01/2012

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