Application Form

AN EQUAL OPPORTUNITIES EMPLOYER

NOTES: Candidate Reference Number

• CVs will not be accepted

• Canvassing will disqualify Ref No: Date of Interview ( )
• Only applications containing all the information
Job Title : Nurse Band 5 (Adult)
which has been sought will be considered
• You are strongly encouraged to complete the Equal
Opportunities monitoring form at the back of this
application form.
• Please complete in Black Ink

For administrative purposes please indicate planned holiday arrangements:

We are under no obligation to take account of your holiday arrangements

Personal Details
Title (Mr, Mrs, Miss, Ms, Dr): Ms First Name (s) Reshma v

Surname: Jojo Previous Surname

Permanent Residence Temporary Residence (if different)

Vattanirappel vellassery
Address kaduthuruthy p.o kottayam Address
kerala 686604

Country India Country

Preferred Address for Contact

(please tick)
Permanent Residence  Temporary Residence

Communication Data – please note correspondence is generally by Email

resh.vjojo@gmail.com
Email Address:

Mobile
Private Telephone Number 7619423442 7619423442
Number
Preferred Number for
Contact (please tick)
Private Number  Mobile Number
References

Please name two suitable referees (not relatives), both of whom should have knowledge of your present or most recent work
as your line manager. If you have worked in a Healthcare setting both references must be from a Healthcare Professional in
a line manager role (if you have ever worked in the NHS / HSC we will also reserve the right to obtain a reference from this
setting).

Title (Mr, Mrs, Miss, Ms, Dr): Mrs Title (Mr, Mrs, Miss, Ms, Dr): Mrs

Name: Reena Menon Name: Deepa S Nair

Occupation Principal Occupation: Associate professor

:
Address: St.johns college of nursing , Address: St.johns college of nursing ,
St.johns medical College hospital St.johns medical College hospital
Koramangala Koramangala
Bangalore ,560034 Bangalore ,560034

Telephone +91 93429 86422 Telephone +91 8123229397

No: No:
Email: principal.sjcn@stjohns.in Email: deepakumaran72@gmail.com

EDUCATION — Please state all School or College level examinations completed

Subjects Passed Examining Body Level Attained Grade Year

10th standard Kerala board of 94% 2014

public
examinations

12th standard Kerala higher 75% 2016

secondary
examination
board

First year bsc nursing Rajive Gandhi First class 68% 2017
University of
health sciences
Second year bsc nursing First class 67% 2018
(St.johns college
of nursing
Third year bsc nursing Bangalore) First class 72% 2019

Fourth year bsc nursing First class 71% 2020

PROFESSIONAL QUALIFICATIONS (e.g. Nursing qualifications)

Name of Professional Expiry Date of

Professional Name of Qualification Date Obtained Body Registration
Body Registration
Number
Karnataka nursing
council (knc) 5 years from issue
St.johns college 25 january 2021
of nursing, BSC nursing
Bangalore

EMPLOYMENT HISTORY – PRESENT POST

Employer Name: Period of Notice:

Employer Address: Fresher Salary/Wage:

Job Dept/Location:

Start Date:

Job Title: Reason for Leaving:

 EMPLOYMENT HISTORY – PREVIOUS POSTS

Please list all your previous posts beginning with the most recent including periods out of employment and any
training.
Period of Employment
Name and Address
Job Title / Reason for
of Employer From To Duties
Job Role Leaving
(dd/mm/yy (dd/mm/y
) y)

If you have any gaps in your career history, please include and explain these in the box below ,
ADDITIONAL INFORMATION

Please include any other information which may be relevant to this application such as a personal statement as to why you wish to
work as a Nurse in Northern Ireland.

PERSONAL DECLARATION
1. I declare that all the foregoing statements are true, complete and accurate
2. I understand that if I give wrong information or leave out important information I could be dismissed if I take up
this job
3. I understand that to take up this job I must have satisfactory references, health assessment and Access NI
checks
4. I understand that I will be asked to show some formal identification and evidence of qualifications
5. I confirm that as far as I know there are no medical reasons which would stop me from carrying out the duties
of this job
6. I agree to you making any necessary enquiries during the recruitment and selection process
7. I understand that canvassing will disqualify me from the selection process for this job
8. I consent to the information I have provided being used within the context of the Data Protection Act 1998 and
understand that my application will be submitted to and processed by TTM Healthcare on behalf of the HSC
to which I am applying but will also be accessible to the HSC Trust (s) during the selection process. I also
understand that if I am successful this application form will be provided to HSC Recruitment Shared Services
Centre for electronic recording as well as the HSC Trust to which I am appointed to support the creation of the
employment relationship and that information herein will be held both in hard copy and electronically.

Your Signature ______________________________________ Date __31 /8/21____________