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NHS STANDARD APPLICATION FORM
Please fill in the application form below. Please remember to check it carefully, as once
the form has been submitted it cannot be changed. Please note that questions marked
with an asterisk * are mandatory and therefore must be answered.

APPLICATION FOR EMPLOYMENT

Details entered in this part of the form will be held by the recruiting employer. Access to this
information will be withheld from the shortlisting panel. Please do not type/write using only
capital letters, as this could lead to your application being automatically rejected. Please use the
appropriate mixture of capital and lowercase letters in standard written text.

Personal Details

Title Miss

*Surname/Family Name Datta

*First Name Mousumi

Middle Name
Name in which you are registered
with a professional body (if Mousumi Datta
applicable)

Dhaleswar,watersupply road
Address

*Postcode/ Zip code 799004

*Country India

Home Telephone (include country

code)

Mobile Telephone (include country

919667144224
code)

Work Telephone (include country

918800779143
code)

Preferred telephone number ◻ Home ◻ Mobile ◻ Work

GLP Application Form June 2017 Confidential Page 1 of 24

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Email Address Mousumidatta445@gmail.com

*Are you a United Kingdom (UK), European Community (EC) or European Economic Area
(EEA) National?

◻ Yes ◻ No

If you have answered ‘no’ above, you must answer these questions:

Please select the category that relates to your current immigration status:

I am intending to apply for a Work Permit/Tier 2 visa

Dependant / Spouse visa

Other, please specify below

Please supply details of any visa currently held:

Visa No:
Start Date: (DD/MM/YY)
Expiry Date: (DD/MM/YY)
Details of any Restriction:

Does your visa have a condition restricting employment or occupation in the UK?

◻ Yes ◻ No

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APPLICATION FOR EMPLOYMENT
Details entered in this part of the form will be held by the recruiting employer and will be made
available to the short-listing panel.

Education & Professional Qualifications

All relevant qualifications. Please also indicate subjects currently being studied. All
qualifications disclosed will be subject to a satisfactory check.
Year
Subject/Qualification Place of Study Grade/result
obtained
madhyamik Tripura 1st 2003 Formatted: Superscript

+2 stage Tripura 1st 2006

G.N.M Trripura 1st 2016

Post bsc bangalore persuing

Training Courses Attended

Training courses that you have attended or details of courses that you are currently
undertaking, together with the date completed or to be completed.
Year
Course Title Training Provider Duration
obtained
Spoken English Iskcon 1 year 2006

CCA Iskcon 1 year 2008

Typing Laxmi commercial college 1 year 2008

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Membership of Professional Bodies or/and Registration Councils

Please provide details regarding any relevant professional registrations or memberships. This
information will be subject to a satisfactory check.

* Please indicate your UK Professional Registration status/home country registration

details/country where practising details

◻ I do not have the relevant UK professional registration status

◻ I have current UK professional registration

◻ UK professional registration required and applied for

◻ UK professional registration required but not yet applied for

◻ I have professional registration in my home country

◻ I have professional registration in the country where I am currently practising

If professional registration is not required then go to Employment History.

Please provide details of registration indicating which country you hold registration in. If you
have more than one registration please provide the details below.

If you have answered ‘I have current UK professional registration relevant for this post’ or ‘I
have current UK professional registration and licence to practise for this post’, then please
enter the relevant details below.
Membership or Membership/Registration Expiry/Renewa
Professional Body
Registration type Number l Date
Tripura Nursinng Council RN & RM TNC-3227 12/05/2021

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If you are applying for a post that requires professional registration you are required to provide
the following information:

Are you currently the subject of a fitness to practise investigation or

proceedings by a licensing or regulatory body in the UK or in any other ◻ Yes
country? ◻ No

If applicable, please provide details of any investigations or proceedings you may be subject
to.

Have you been removed from the register or have conditions been made
on your registration by a fitness to practise committee or the licensing or ◻Yes
regulatory body in the UK or in any other country? ◻ No

If applicable, please provide details of any conditions you may have.

Employment History
Please record below the details of your full employment history beginning with your current or
most recent first. If required, please provide additional information regarding your employment
history within the 'Supporting Information' section.

Start of continuous NHS service (If applicable) (MM/YYYY)

Months since most recent employment ended (if

applicable)

Current/most recent employer

Klay Daycare and pre school

Employer Name

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Address Gurgaon sctor 82

Type of Business Telephone

Job Title Senior executive nurse

Start Date (MM/YYYY) 06/05/2019 End Date (MM/YYYY)

Grade Salary 264000 per annum

Reporting to (job
Senior executive nurse Period of notice 1 month
title)
Reason for leaving (if applicable)

Still working

Brief description of your duties and responsibilities

Checking vitals and giving medication,
Follow nursing proceesss in assessing,planning,implementation,and evaluating daily individual patient
care.
Checking intake and output.
Asssisting and performing CPR.
Wound dressing.
Maintaining hourly chart of vitals.
Supervision of staff and students.
Maintainance of records and reports.
Maintaining inter personal relationship.

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Previous Employer 1

Employer Name C.K Birla group of Hospitals

Address Alipore,Kolkata

Type of Business Telephone

Job Title Senior Executive Nurse

Start Date (MM/YYYY) 16/08/2016 End Date (MM/YYYY) 03/09/2018

Grade Salary 224000 per annum

Reporting to (job
Period of notice 1 month completed
title)
Reason for leaving (if applicable)

Shifted from Kolkata to Delhi

Brief description of your duties and responsibilities

Checking vitals and giving medication,
Follow nursing proceesss in assessing,planning,implementation,and evaluating daily individual patient
care.
Checking intake and output.
Asssisting and performing CPR.
Wound dressing.
Maintaining hourly chart of vitals.
Supervision of staff and students.
Maintainance of records and reports.
Maintaining inter personal relationship.
Admission of patients according to the hospital procedure.
Transfer and discharge of patients.
Maintaining patient airway,performing tracheal,oral,and nasal suctioning as required.adequate chest
physiotherapy to mobilize the secretions.Minimum 2 hourly change of positions,giving stem
inhalations,mobilizations,administering oxygen.
Care of patient with oxygen and ventilators.
Performing intra venous canalization.
Sending blood samples and evaluating the lab values.

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Assisting in endotracheal intubation.
Urinary catheterization.
Setting up of crash trolley wwith all emergency drugs.
Maintaing Glasgow Comas Scale..
CVP and intra arterial pressure monitoring.
Preparing patients for surgery,endoscopy,bronchoscopy etc.
Inserting NG tube and giving NG feed.
Administering enema and suppositories.
Urinary catheterization,bladder wash and catheter care..
Providing healthy information to the client and family regarding vaccinations,prevention of disease
using universal precautions.
Monitoring arterial blood gases and electrolyte levels.

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Previous Employer 2

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job
Period of notice
title)
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

Previous Employer 3

Employer Name

Address

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Type of Business Telephone
Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job
Period of notice
title)
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

Previous Employer 4

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job
Period of notice
title)

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Reason for leaving (if applicable)

Brief description of your duties and responsibilities

Previous Employer 5

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job
Period of notice
title)
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

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Previous Employer 6

Employer Name

Address

Type of Business Telephone

Job Title
Start Date (MM/YYYY) End Date (MM/YYYY)
Grade Salary
Reporting to (job
Period of notice
title)
Reason for leaving (if applicable)

Brief description of your duties and responsibilities

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Please add additional employers/information on a separate sheet.

Employment Gaps

If you have any gaps within your employment history, please state the reasons for the gaps
below.

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References
Please provide the names and full contact details of the people who have agreed to supply
references. References must include at least two positions with separate employers and, as a
minimum, cover a period of three years employment and/or training history, where this is
possible.

Referees will be required to comment on your competence, personal qualities and suitability for
the post. This may be your line/department manager, or someone in a position of responsibility
for any work experience or placement undertaken. If you are a student or trainee this should
include a teacher/tutor at your education institution.

If you have not been in employment for a considerable amount of time but have had previous
employment, then you should seek one reference from your last known employer and a
personal reference from a person of standing within your community such as a doctor, solicitor
or MP. Where it is genuinely not possible to obtain references from any of the sources outlined
above, you must provide contact details of two personal acquaintances who would be willing to
give a reference. Personal acquaintances must not be related to you, or have any financial
arrangement with you.

Please note that all reference requests will be followed up and verified by the recruiting
employer.

Referees may be approached prior to interview, unless you indicate otherwise below.

Referee 1
* Type of Reference ◻ Employer ◻ Educational ◻ Personal

Title Mr

*Surname/Family name Mondal * First Name Sayantan

*Relationship Cousin brother

Employer Name Experion group of real estate

Referee Job Title Legal consultant

*Address Gurgaon sector 82

*Postcode/ Zip Code 122002

Telephone 8800779143 *Country

Email Sayantangnlu@gmail..com Fax
*Can the referee be
contacted prior to ◻ Yes ◻ No
interview?

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Referee 2
* Type of Reference ◻ Employer ◻ Educational ◻ Personal

Title Miss

*Surname/Family name Begum * First Name Rasheda

*Relationship Coleguue

Employer name C K Birla group of Hospitals

Referee Job Title Senior Executive Nurse

*Address Agartala,Tripura

*Post Code/ Zip Code 799001

Telephone 919089315893 *Country

Email Fax
*Can the referee be
contacted prior to ◻ Yes ◻ No
interview?

If you have applied to us within the last 3 months,

are you happy for us to use the references from ◻ Yes ◻ No
your earlier application?

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Supporting Information
In this section please give your reasons for applying to work in the NHS and supply any
additional information which demonstrates your abilities. This can include relevant skills,
knowledge, experience, voluntary activities, training etc.

Experience can also include for example details about research experience, publications or
poster presentations, clinical care (knowledge and skills) and clinical audit.

* Supporting information (Please continue on additional sheets if necessary).

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Additional Personal Information

Declaration
The information in this form is true and complete. I agree that any deliberate omission,
falsification or misrepresentation in the application form will be grounds for rejecting this
application or subsequent dismissal if employed by the organisation. Where applicable, I
consent that the organisation can seek clarification regarding professional registration details.

I agree to the above declaration

Signature

Name MOUSUMI DATTA Date

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MONITORING INFORMATION
NHS organisations recognise the benefits of having a diverse workforce and therefore welcome
applications from all sections of the community. In addition to this, under the provisions of the
Equality Act 2010, all NHS organisations are required to demonstrate that their recruitment
processes are fair and that they are not discriminating against or disadvantaging anyone
because of their age, disability, gender reassignment status, marriage or civil partnership status,
pregnancy or maternity, race, religion or belief, sex or sexual orientation. Therefore a series of
questions need to be raised in order to ascertain who is applying for each position and to
ensure that no one is being unfairly discriminated against or disadvantaged.

This section of the application form will be detached from your application and will not be used
as part of the selection process nor will it be seen by anybody who is interviewing you. The
information collected is only used for monitoring purposes in an anonymised format to assist the
organisation in analysing the profile and make up of individuals who apply, are shortlisted for
and appointed to each vacancy. In this way, they can ch
eck that they are complying with the Equality Act 2010.

Equality Act 2010

The Equality Act 2010 protects people against discrimination on the grounds of their age and
sex.

* Please state your date of birth 28/08/1987

◻ Male
* Please indicate your gender ◻ Female
◻ I do not wish to disclose this

Equality Act 2010

The Equality Act 2010 protects people who are married or in a civil partnership.
* Please indicate the option which best describes your marital status

◻ Married
◻ Divorced
◻ Single
◻ Widowed
◻ Civil partnership
◻ I do not wish to disclose this
◻ Legally separated

Equality Act 2010

The Equality Act 2010 protects bisexual, gay, heterosexual and lesbian people from
discrimination on the grounds of their sexual orientation.

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* Please indicate the option which best describes your sexual orientation

◻ Lesbian
◻ Gay ◻ Heterosexual

◻ Bisexual ◻ I do not wish to disclose this

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Equality Act 2010
The Equality Act 2010 protects people against discrimination on the grounds of their race which
includes colour, nationality, ethnic or national origin.

* Please indicate your ethnic origin

Asian or Asian British Mixed Other Ethnic Group

◻ Bangladeshi ◻ White & Asian ◻ Chinese
◻ Indian ◻ White & Black African ◻ Any other ethnic group
◻ Pakistani ◻ White & Black Caribbean
◻ Any other Asian ◻ Any other mixed background
◻ I do not wish to
background
disclose this
White
Black or Black British ◻ British
◻ African
◻ Irish
◻ Caribbean
◻ Any other White background
◻ Any other Black
background

Equality Act 2010

The Equality Act 2010 protects people against discrimination on the grounds of their religion or
belief, including a lack of any belief.
* Please indicate your religion or belief

◻ Atheism ◻ Islam ◻ Other

◻ Buddhism ◻ Jainism ◻ I do not wish to disclose
◻ Christianity ◻ Judaism this

◻ Hinduism ◻ Sikhism

Equality Act 2010

The Equality Act 2010 protects disabled people - including those with long term health
conditions, learning disabilities and so called "hidden" disabilities such as dyslexia. If you tell us
that you have a disability we can make reasonable adjustments to ensure that any selection
processes - including the interview - are fair and equitable.

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* Do you consider yourself to ◻ Yes ◻ No

have a disability? ◻ I do not wish to disclose this information

Please state the type of impairment which applies to you. People may experience more than
one type of impairment, in which case you may indicate more than one. If none of the
categories apply, please mark ‘other’.

◻ Physical impairment ◻ Learning Disability/Difficulty

◻ Sensory impairment ◻ Long-standing illness
◻ Mental health condition ◻ Other

If you have a disability, do you wish to be considered under the guaranteed interview scheme
if you meet the minimum criteria as specified in the person specification?

◻ Yes ◻ No

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Rehabilitation of Offenders Act 1974
The Rehabilitation of Offenders Act 1974 (as amended) helps rehabilitated ex-offenders back
into work by allowing them not to declare criminal convictions after the rehabilitation period set
by the Court has elapsed and the convictions become 'spent'. During the rehabilitation period,
convictions are referred to as 'unspent' convictions and must be declared to employers.

The organisation aims to promote equality of opportunity and is committed to treating all
applicants for positions fairly and on merit regardless oSf ethnicity, disability, age, gender or
gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and
marriage or civil partnership. The organisation undertakes not to discriminate unfairly against
applicants on the basis of a criminal conviction or other information declared.

You are required to declare all current ‘unspent’ criminal convictions or cautions (including
reprimands and final warnings). You are not required to disclose convictions or cautions which
have become ‘spent’.

As part of assessing your application, organisations will only take into account relevant criminal
record and other information declared which is relevant to the position being applied for.

Answering ‘yes’ to the question below will not necessarily bar you from appointment. This will
depend on the relevance of the information you provide in respect of the nature of the position
for which you are applying and the particular circumstances.

* Are you currently bound over or do you have any current ‘unspent’ convictions or cautions
(including reprimands or warnings) that have beSsSen issued by a Court or Court-Martial in
the United Kingdom or in any other country?

◻ Yes ◻ No

If Yes, please include details of the order binding you over and/or the nature of the offence,
the penalty, sentence or order of the Court, and the date and place of the Court hearing. You
do not need to tell us about parking offences.

Relationships

If you are related to a director, or have a relationship with a director or employee of an

appointing organisation, please state the relationship:

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